- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,892.74 / $1,892.74 / $1,892.74
| Facility | | $1,892.74 | $1,892.74 | $1,892.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,892.74 / $1,892.74 / $1,892.74
| Professional | | $1,892.74 | $1,892.74 | $1,892.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,901.81 / $2,028.60 / $2,474.51
| Professional | | $1,901.81 | $2,028.60 | $2,474.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,431.96 / $2,431.96 / $2,431.96
| Professional | | $2,431.96 | $2,431.96 | $2,431.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,352.91 / $2,352.91 / $7,185.64
| Professional | | $2,352.91 | $2,352.91 | $7,185.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,203.94 / $1,805.91 / $2,558.37
| Professional | | $1,203.94 | $1,805.91 | $2,558.37 |