- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,980.92 / $1,980.92 / $1,980.92
| Facility | | $1,980.92 | $1,980.92 | $1,980.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,980.92 / $1,980.92 / $1,980.92
| Professional | | $1,980.92 | $1,980.92 | $1,980.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,074.75 / $2,074.75 / $2,074.75
| Professional | | $2,074.75 | $2,074.75 | $2,074.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,954.85 / $1,954.85 / $1,954.85
| Professional | | $1,954.85 | $1,954.85 | $1,954.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,415.67 / $2,415.67 / $7,377.34
| Professional | | $2,415.67 | $2,415.67 | $7,377.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,236.06 / $1,854.09 / $2,820.42
| Professional | | $1,236.06 | $1,854.09 | $2,820.42 |