- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,426.25 / $1,426.25 / $1,426.25
| Facility | | $1,426.25 | $1,426.25 | $1,426.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,426.25 / $1,426.25 / $1,426.25
| Professional | | $1,426.25 | $1,426.25 | $1,426.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,435.00 / $1,435.00 / $1,829.16
| Professional | | $1,435.00 | $1,435.00 | $1,829.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,431.35 / $1,431.35 / $1,431.35
| Professional | | $1,431.35 | $1,431.35 | $1,431.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,739.27 / $1,739.27 / $5,311.63
| Professional | | $1,739.27 | $1,739.27 | $5,311.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $889.95 / $1,334.93 / $2,281.65
| Professional | | $889.95 | $1,334.93 | $2,281.65 |