- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,745.28 / $1,745.28 / $1,745.28
| Facility | | $1,745.28 | $1,745.28 | $1,745.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,745.28 / $1,745.28 / $1,745.28
| Professional | | $1,745.28 | $1,745.28 | $1,745.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,756.00 / $1,756.00 / $1,756.00
| Professional | | $1,756.00 | $1,756.00 | $1,756.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,967.06 / $1,967.06 / $1,967.06
| Professional | | $1,967.06 | $1,967.06 | $1,967.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,128.33 / $2,128.33 / $6,499.78
| Professional | | $2,128.33 | $2,128.33 | $6,499.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,089.03 / $1,633.54 / $2,314.17
| Professional | | $1,089.03 | $1,633.54 | $2,314.17 |