- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,505.85 / $2,505.85 / $2,505.85
| Facility | | $2,505.85 | $2,505.85 | $2,505.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,505.85 / $2,505.85 / $2,505.85
| Professional | | $2,505.85 | $2,505.85 | $2,505.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,521.00 / $2,521.00 / $3,213.75
| Professional | | $2,521.00 | $2,521.00 | $3,213.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,772.60 / $2,772.60 / $2,772.60
| Professional | | $2,772.60 | $2,772.60 | $2,772.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,055.82 / $3,055.82 / $9,332.27
| Professional | | $3,055.82 | $3,055.82 | $9,332.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,563.60 / $2,345.41 / $3,322.66
| Professional | | $1,563.60 | $2,345.41 | $3,322.66 |