- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,057.17 / $2,057.17 / $2,057.17
| Facility | | $2,057.17 | $2,057.17 | $2,057.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,057.17 / $2,057.17 / $2,057.17
| Professional | | $2,057.17 | $2,057.17 | $2,057.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,154.59 / $2,154.59 / $2,638.31
| Professional | | $2,154.59 | $2,154.59 | $2,638.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,407.09 / $2,407.09 / $2,407.09
| Professional | | $2,407.09 | $2,407.09 | $2,407.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,508.66 / $2,508.66 / $7,661.29
| Professional | | $2,508.66 | $2,508.66 | $7,661.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,116.77 / $6,116.77 / $6,116.77
| Facility | | $6,116.77 | $6,116.77 | $6,116.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,283.63 / $1,925.45 / $2,727.72
| Professional | | $1,283.63 | $1,925.45 | $2,727.72 |