- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,655.37 / $1,655.37 / $1,655.37
| Facility | | $1,655.37 | $1,655.37 | $1,655.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,655.37 / $1,655.37 / $1,655.37
| Professional | | $1,655.37 | $1,655.37 | $1,655.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,849.70 / $1,973.02 / $2,406.73
| Professional | | $1,849.70 | $1,973.02 | $2,406.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,915.69 / $1,915.69 / $1,915.69
| Professional | | $1,915.69 | $1,915.69 | $1,915.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,288.46 / $2,288.46 / $6,988.79
| Professional | | $2,288.46 | $2,288.46 | $6,988.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,170.96 / $1,756.43 / $2,488.28
| Professional | | $1,170.96 | $1,756.43 | $2,488.28 |