- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,908.33 / $2,908.33 / $2,908.33
| Facility | | $2,908.33 | $2,908.33 | $2,908.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,908.33 / $2,908.33 / $2,908.33
| Professional | | $2,908.33 | $2,908.33 | $2,908.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,926.00 / $2,926.00 / $3,729.94
| Professional | | $2,926.00 | $2,926.00 | $3,729.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,572.44 / $2,572.44 / $2,572.44
| Professional | | $2,572.44 | $2,572.44 | $2,572.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,546.63 / $3,546.63 / $10,831.20
| Professional | | $3,546.63 | $3,546.63 | $10,831.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,814.75 / $2,722.12 / $3,856.34
| Professional | | $1,814.75 | $2,722.12 | $3,856.34 |