- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,096.56 / $2,096.56 / $2,096.56
| Facility | | $2,096.56 | $2,096.56 | $2,096.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,096.56 / $2,096.56 / $2,096.56
| Professional | | $2,096.56 | $2,096.56 | $2,096.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,147.08 / $2,147.08 / $2,147.08
| Professional | | $2,147.08 | $2,147.08 | $2,147.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $410.74 / $2,301.61
| Professional | | $45.00 | $410.74 | $2,301.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,399.67 / $2,956.89 / $3,112.38
| Professional | | $2,399.67 | $2,956.89 | $3,112.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,104.98 / $2,104.98 / $2,104.98
| Professional | | $2,104.98 | $2,104.98 | $2,104.98 |