- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Facility | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $2,818.38
| Professional | | $1,905.46 | $1,905.46 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,365.16 / $5,370.32
| Professional | | $4,265.80 | $4,365.16 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $2,454.71
| Facility | | $1,905.46 | $1,905.46 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $2,511.89
| Professional | | $2,511.89 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $54.95
| Professional | | $30.20 | $30.20 | $54.95 |