- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,343.25 / $2,343.25 / $2,343.25
| Facility | | $2,343.25 | $2,343.25 | $2,343.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,343.25 / $2,343.25 / $2,343.25
| Professional | | $2,343.25 | $2,343.25 | $2,343.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.23 / $2,454.23 / $2,454.23
| Professional | | $2,454.23 | $2,454.23 | $2,454.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,456.42 / $2,456.42 / $2,456.42
| Professional | | $2,456.42 | $2,456.42 | $2,456.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,857.53 / $2,857.53 / $8,726.70
| Professional | | $2,857.53 | $2,857.53 | $8,726.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,462.14 / $2,193.21 / $3,336.30
| Professional | | $1,462.14 | $2,193.21 | $3,336.30 |