- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,372.87 / $2,372.87 / $2,372.87
| Facility | | $2,372.87 | $2,372.87 | $2,372.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,372.87 / $2,372.87 / $2,372.87
| Professional | | $2,372.87 | $2,372.87 | $2,372.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,481.96 / $2,481.96 / $3,043.21
| Professional | | $2,481.96 | $2,481.96 | $3,043.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.39 / $2,001.39 / $2,001.39
| Professional | | $2,001.39 | $2,001.39 | $2,001.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,893.66 / $2,893.66 / $8,837.04
| Professional | | $2,893.66 | $2,893.66 | $8,837.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,480.63 / $2,220.94 / $3,146.33
| Professional | | $1,480.63 | $2,220.94 | $3,146.33 |