- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,321.32 / $1,321.32 / $1,321.32
| Facility | | $1,321.32 | $1,321.32 | $1,321.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,321.32 / $1,321.32 / $1,321.32
| Professional | | $1,321.32 | $1,321.32 | $1,321.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,731.00 / $1,731.00 / $1,731.00
| Professional | | $1,731.00 | $1,731.00 | $1,731.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.61 / $1,472.61 / $1,472.61
| Professional | | $1,472.61 | $1,472.61 | $1,472.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,098.44 / $2,098.44 / $6,408.53
| Professional | | $2,098.44 | $2,098.44 | $6,408.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,073.74 / $1,610.60 / $3,015.14
| Professional | | $1,073.74 | $1,610.60 | $3,015.14 |