- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,743.10 / $2,743.10 / $2,743.10
| Facility | | $2,743.10 | $2,743.10 | $2,743.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,743.10 / $3,130.56 / $3,428.88
| Professional | | $2,743.10 | $3,130.56 | $3,428.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,550.23 / $3,010.77 / $3,053.97
| Professional | | $2,550.23 | $3,010.77 | $3,053.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,914.55 / $2,914.55 / $4,829.66
| Professional | | $2,914.55 | $2,914.55 | $4,829.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,743.10 / $3,428.88 / $4,886.16
| Facility | | $2,743.10 | $3,428.88 | $4,886.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,857.40 / $2,857.40 / $13,029.74
| Professional | | $2,857.40 | $2,857.40 | $13,029.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,857.40 / $2,857.40 / $3,143.14
| Professional | | $2,857.40 | $2,857.40 | $3,143.14 |