- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,126.64 / $2,126.64 / $2,126.64
| Facility | | $2,126.64 | $2,126.64 | $2,126.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,126.64 / $2,126.64 / $2,126.64
| Professional | | $2,126.64 | $2,126.64 | $2,126.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,136.86 / $2,136.86 / $2,136.86
| Professional | | $2,136.86 | $2,136.86 | $2,136.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,732.53 / $2,732.53 / $2,732.53
| Professional | | $2,732.53 | $2,732.53 | $2,732.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,643.71 / $2,643.71 / $8,073.72
| Professional | | $2,643.71 | $2,643.71 | $8,073.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,352.74 / $2,029.11 / $2,874.57
| Professional | | $1,352.74 | $2,029.11 | $2,874.57 |