- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,931.74 / $1,931.74 / $1,931.74
| Facility | | $1,931.74 | $1,931.74 | $1,931.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,931.74 / $1,931.74 / $1,931.74
| Professional | | $1,931.74 | $1,931.74 | $1,931.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,943.00 / $1,943.00 / $2,477.44
| Professional | | $1,943.00 | $1,943.00 | $2,477.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,807.55 / $1,807.55 / $1,807.55
| Professional | | $1,807.55 | $1,807.55 | $1,807.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,355.69 / $2,355.69 / $7,194.17
| Professional | | $2,355.69 | $2,355.69 | $7,194.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,205.36 / $1,808.05 / $2,561.41
| Professional | | $1,205.36 | $1,808.05 | $2,561.41 |