- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,050.28 / $2,050.28 / $2,050.28
| Facility | | $2,050.28 | $2,050.28 | $2,050.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,050.28 / $2,050.28 / $2,050.28
| Professional | | $2,050.28 | $2,050.28 | $2,050.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,063.00 / $2,063.00 / $2,063.00
| Professional | | $2,063.00 | $2,063.00 | $2,063.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,576.85 / $1,576.85 / $1,576.85
| Professional | | $1,576.85 | $1,576.85 | $1,576.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.26 / $2,500.26 / $7,635.65
| Professional | | $2,500.26 | $2,500.26 | $7,635.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,279.33 / $1,919.01 / $2,718.60
| Professional | | $1,279.33 | $1,919.01 | $2,718.60 |