- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,705.43 / $2,705.43 / $2,705.43
| Facility | | $2,705.43 | $2,705.43 | $2,705.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,705.43 / $2,705.43 / $2,705.43
| Professional | | $2,705.43 | $2,705.43 | $2,705.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,225.76 / $3,225.76 / $3,469.72
| Professional | | $3,225.76 | $3,225.76 | $3,469.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,426.50 / $2,426.50 / $2,426.50
| Professional | | $2,426.50 | $2,426.50 | $2,426.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,299.21 / $3,299.21 / $10,075.57
| Professional | | $3,299.21 | $3,299.21 | $10,075.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,688.14 / $2,532.21 / $3,851.98
| Professional | | $1,688.14 | $2,532.21 | $3,851.98 |