- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,062.98 / $2,062.98 / $2,062.98
| Facility | | $2,062.98 | $2,062.98 | $2,062.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,062.98 / $2,062.98 / $2,062.98
| Professional | | $2,062.98 | $2,062.98 | $2,062.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,078.40 / $2,797.60 / $2,797.60
| Professional | | $2,078.40 | $2,797.60 | $2,797.60 |
- 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
- $103.27 / $159.50 / $404.51
| Professional | | $103.27 | $159.50 | $404.51 |