- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,337.65 / $2,337.65 / $2,337.65
| Facility | | $2,337.65 | $2,337.65 | $2,337.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,337.65 / $2,337.65 / $2,337.65
| Facility | | $2,337.65 | $2,337.65 | $2,337.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,337.65 / $2,337.65 / $2,337.65
| Professional | | $2,337.65 | $2,337.65 | $2,337.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,519.47 / $1,595.44 / $1,773.22
| Facility | | $1,519.47 | $1,595.44 | $1,773.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.46 / $1,064.61 / $2,801.29
| Professional | | $1,000.46 | $1,064.61 | $2,801.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.81 / $1,402.59 / $3,506.48
| Professional | | $981.81 | $1,402.59 | $3,506.48 |