- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,932.70 / $1,932.70 / $1,932.70
| Facility | | $1,932.70 | $1,932.70 | $1,932.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,796.21 / $1,845.88 / $2,273.32
| Professional | | $1,796.21 | $1,845.88 | $2,273.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,006.50 / $2,006.50 / $2,006.50
| Professional | | $2,006.50 | $2,006.50 | $2,006.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,020.53 / $2,020.53 / $2,020.53
| Professional | | $2,020.53 | $2,020.53 | $2,020.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,763.36 / $1,938.17 / $2,477.92
| Facility | | $1,763.36 | $1,938.17 | $2,477.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,000.00 / $3,000.00 / $3,000.00
| Professional | | $3,000.00 | $3,000.00 | $3,000.00 |