- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,974.01 / $1,974.01 / $1,974.01
| Facility | | $1,974.01 | $1,974.01 | $1,974.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,974.01 / $1,974.01 / $1,974.01
| Professional | | $1,974.01 | $1,974.01 | $1,974.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,986.00 / $1,986.00 / $2,531.67
| Professional | | $1,986.00 | $1,986.00 | $2,531.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,168.71 / $2,168.71 / $2,168.71
| Professional | | $2,168.71 | $2,168.71 | $2,168.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,407.26 / $2,407.26 / $7,351.61
| Professional | | $2,407.26 | $2,407.26 | $7,351.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,231.75 / $1,847.62 / $3,157.93
| Professional | | $1,231.75 | $1,847.62 | $3,157.93 |