- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,326.37 / $2,326.37 / $2,326.37
| Facility | | $2,326.37 | $2,326.37 | $2,326.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,326.36 / $2,326.37 / $2,326.37
| Professional | | $2,326.36 | $2,326.37 | $2,326.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,189.53 / $2,189.53 / $2,189.53
| Professional | | $2,189.53 | $2,189.53 | $2,189.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,554.44 / $2,554.44 / $2,554.44
| Professional | | $2,554.44 | $2,554.44 | $2,554.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.40 / $124.69 / $161.10
| Professional | | $107.40 | $124.69 | $161.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,325.69 / $2,736.91 / $2,819.02
| Professional | | $2,325.69 | $2,736.91 | $2,819.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.41 / $110.41 / $110.41
| Professional | | $110.41 | $110.41 | $110.41 |