- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,972.40 / $1,972.40 / $1,972.40
| Facility | | $1,972.40 | $1,972.40 | $1,972.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,972.40 / $1,972.40 / $1,972.40
| Professional | | $1,972.40 | $1,972.40 | $1,972.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,984.00 / $1,984.00 / $2,529.60
| Professional | | $1,984.00 | $1,984.00 | $2,529.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,983.86 / $1,983.86 / $1,983.86
| Professional | | $1,983.86 | $1,983.86 | $1,983.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,405.29 / $2,405.29 / $7,345.61
| Professional | | $2,405.29 | $2,405.29 | $7,345.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.74 / $1,846.11 / $2,808.29
| Professional | | $1,230.74 | $1,846.11 | $2,808.29 |