- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,757.88 / $1,757.88 / $1,757.88
| Facility | | $1,757.88 | $1,757.88 | $1,757.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,757.88 / $1,757.88 / $1,757.88
| Professional | | $1,757.88 | $1,757.88 | $1,757.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,625.00 / $2,625.00 / $2,783.34
| Professional | | $2,625.00 | $2,625.00 | $2,783.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,586.91 / $2,586.91 / $6,278.05
| Professional | | $2,586.91 | $2,586.91 | $6,278.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,250.83 / $2,092.14 / $2,092.14
| Professional | | $1,250.83 | $2,092.14 | $2,092.14 |