- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,282.25 / $2,282.25 / $2,282.25
| Facility | | $2,282.25 | $2,282.25 | $2,282.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,282.25 / $2,282.25 / $2,282.25
| Professional | | $2,282.25 | $2,282.25 | $2,282.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,675.00 / $2,675.00 / $2,926.99
| Professional | | $2,675.00 | $2,675.00 | $2,926.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,787.62 / $1,787.62 / $1,787.62
| Professional | | $1,787.62 | $1,787.62 | $1,787.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,783.14 / $2,783.14 / $8,499.54
| Professional | | $2,783.14 | $2,783.14 | $8,499.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,424.08 / $2,136.13 / $3,249.46
| Professional | | $1,424.08 | $2,136.13 | $3,249.46 |