- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,910.52 / $2,910.52 / $2,910.52
| Facility | | $2,910.52 | $2,910.52 | $2,910.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,910.52 / $2,910.52 / $2,910.52
| Professional | | $2,910.52 | $2,910.52 | $2,910.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,926.39 / $3,060.08 / $3,732.74
| Professional | | $2,926.39 | $3,060.08 | $3,732.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,721.75 / $2,721.75 / $2,721.75
| Professional | | $2,721.75 | $2,721.75 | $2,721.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,549.30 / $3,549.30 / $10,839.33
| Professional | | $3,549.30 | $3,549.30 | $10,839.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,816.11 / $2,724.16 / $3,859.23
| Professional | | $1,816.11 | $2,724.16 | $3,859.23 |