- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,701.31 / $1,701.31 / $1,701.31
| Facility | | $1,701.31 | $1,701.31 | $1,701.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,701.31 / $1,701.31 / $1,701.31
| Professional | | $1,701.31 | $1,701.31 | $1,701.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,709.47 / $1,709.47 / $1,709.47
| Professional | | $1,709.47 | $1,709.47 | $1,709.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,537.05 / $1,537.05 / $1,537.05
| Professional | | $1,537.05 | $1,537.05 | $1,537.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,114.94 / $2,114.94 / $6,458.92
| Professional | | $2,114.94 | $2,114.94 | $6,458.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,082.18 / $1,623.28 / $2,299.64
| Professional | | $1,082.18 | $1,623.28 | $2,299.64 |