- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,073.38 / $2,073.38 / $2,073.38
| Facility | | $2,073.38 | $2,073.38 | $2,073.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,073.38 / $3,403.99 / $3,403.99
| Professional | | $2,073.38 | $3,403.99 | $3,403.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,384.12 / $3,384.12 / $4,588.29
| Facility | | $3,384.12 | $3,384.12 | $4,588.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,384.12 / $3,384.12 / $19,187.84
| Professional | | $3,384.12 | $3,384.12 | $19,187.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $6,082.86
| Professional | | $4,200.00 | $4,200.00 | $6,082.86 |