- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,102.67 / $2,102.67 / $2,102.67
| Facility | | $2,102.67 | $2,102.67 | $2,102.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,102.67 / $2,102.67 / $2,102.67
| Professional | | $2,102.67 | $2,102.67 | $2,102.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,202.25 / $2,202.25 / $2,696.67
| Professional | | $2,202.25 | $2,202.25 | $2,696.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,811.20 / $1,811.20 / $1,811.20
| Professional | | $1,811.20 | $1,811.20 | $1,811.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,564.15 / $2,564.15 / $7,830.73
| Professional | | $2,564.15 | $2,564.15 | $7,830.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,312.02 / $1,968.04 / $2,788.05
| Professional | | $1,312.02 | $1,968.04 | $2,788.05 |