- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,439.52 / $2,439.52 / $2,439.52
| Facility | | $2,439.52 | $2,439.52 | $2,439.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,439.52 / $2,439.52 / $2,439.52
| Professional | | $2,439.52 | $2,439.52 | $2,439.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.00 / $2,454.00 / $3,128.69
| Professional | | $2,454.00 | $2,454.00 | $3,128.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,578.61 / $2,578.61 / $2,578.61
| Professional | | $2,578.61 | $2,578.61 | $2,578.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,974.93 / $2,974.93 / $9,085.25
| Professional | | $2,974.93 | $2,974.93 | $9,085.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,522.22 / $2,283.32 / $3,234.71
| Professional | | $1,522.22 | $2,283.32 | $3,234.71 |