- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,354.80 / $2,354.80 / $2,354.80
| Facility | | $2,354.80 | $2,354.80 | $2,354.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,354.80 / $2,354.80 / $2,354.80
| Professional | | $2,354.80 | $2,354.80 | $2,354.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,670.33 / $2,670.33 / $2,670.33
| Professional | | $2,670.33 | $2,670.33 | $2,670.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,342.58 / $1,342.58 / $1,342.58
| Professional | | $1,342.58 | $1,342.58 | $1,342.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.77 / $175.58 / $484.78
| Professional | | $122.77 | $175.58 | $484.78 |