- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $2,784.38
| Facility | | $2,784.38 | $2,784.38 | $2,784.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $2,784.38
| Professional | | $2,784.38 | $2,784.38 | $2,784.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.77 / $217.77 / $217.77
| Professional | | $217.77 | $217.77 | $217.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,626.77 / $2,626.77 / $2,784.38
| Facility | | $2,626.77 | $2,626.77 | $2,784.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $3,546.14
| Professional | | $2,784.38 | $2,784.38 | $3,546.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,366.71 / $2,366.71 / $3,780.00
| Professional | | $2,366.71 | $2,366.71 | $3,780.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $4,512.87
| Professional | | $2,784.38 | $2,784.38 | $4,512.87 |