- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,487.37 / $1,487.37 / $1,487.37
| Facility | | $1,487.37 | $1,487.37 | $1,487.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,487.37 / $1,487.37 / $1,487.37
| Professional | | $1,487.37 | $1,487.37 | $1,487.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,859.21 / $2,305.00 / $4,760.00
| Professional | | $1,859.21 | $2,305.00 | $4,760.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,974.99 / $2,974.99 / $2,974.99
| Facility | | $2,974.99 | $2,974.99 | $2,974.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,708.99 / $1,708.99 / $2,136.23
| Professional | | $1,708.99 | $1,708.99 | $2,136.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $624.70 / $624.70 / $1,487.37
| Professional | | $624.70 | $624.70 | $1,487.37 |