- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,947.64 / $1,947.64 / $1,947.64
| Facility | | $1,947.64 | $1,947.64 | $1,947.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,947.64 / $1,947.64 / $1,947.64
| Professional | | $1,947.64 | $1,947.64 | $1,947.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,039.87 / $2,039.87 / $2,497.85
| Professional | | $2,039.87 | $2,039.87 | $2,497.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.30 / $1,653.30 / $1,653.30
| Professional | | $1,653.30 | $1,653.30 | $1,653.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,375.09 / $2,375.09 / $7,253.39
| Professional | | $2,375.09 | $2,375.09 | $7,253.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,215.29 / $1,822.93 / $2,582.48
| Professional | | $1,215.29 | $1,822.93 | $2,582.48 |