- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $1,494.41
| Facility | | $1,494.41 | $1,494.41 | $1,494.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $1,789.00
| Professional | | $1,494.41 | $1,494.41 | $1,789.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $1,494.41
| Professional | | $1,494.41 | $1,494.41 | $1,494.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $1,494.41
| Facility | | $1,494.41 | $1,494.41 | $1,494.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $2,941.31
| Professional | | $1,494.41 | $1,494.41 | $2,941.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,300.14 / $1,494.41 / $1,793.29
| Professional | | $1,300.14 | $1,494.41 | $1,793.29 |