- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,972.26 / $1,972.26 / $1,972.26
| Facility | | $1,972.26 | $1,972.26 | $1,972.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,972.26 / $1,972.26 / $1,972.26
| Professional | | $1,972.26 | $1,972.26 | $1,972.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,931.60 / $2,931.60 / $2,931.60
| Professional | | $2,931.60 | $2,931.60 | $2,931.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,012.35 / $2,012.35 / $2,012.35
| Professional | | $2,012.35 | $2,012.35 | $2,012.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,132.24 / $3,132.24 / $9,565.66
| Professional | | $3,132.24 | $3,132.24 | $9,565.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,602.71 / $2,240.54 / $3,612.11
| Professional | | $1,602.71 | $2,240.54 | $3,612.11 |