- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,383.46 / $2,383.46 / $2,383.46
| Facility | | $2,383.46 | $2,383.46 | $2,383.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,383.46 / $2,383.46 / $2,383.46
| Professional | | $2,383.46 | $2,383.46 | $2,383.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.00 / $2,398.00 / $2,398.00
| Professional | | $2,398.00 | $2,398.00 | $2,398.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.06 / $2,784.06 / $2,784.06
| Professional | | $2,784.06 | $2,784.06 | $2,784.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,906.57 / $2,906.57 / $8,876.50
| Professional | | $2,906.57 | $2,906.57 | $8,876.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,487.24 / $2,230.86 / $3,160.39
| Professional | | $1,487.24 | $2,230.86 | $3,160.39 |