- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,086.76 / $1,086.76 / $1,086.76
| Facility | | $1,086.76 | $1,086.76 | $1,086.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,086.76 / $1,086.76 / $1,086.76
| Professional | | $1,086.76 | $1,086.76 | $1,086.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $844.88 / $844.88 / $844.88
| Professional | | $844.88 | $844.88 | $844.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.00 / $102.00 / $102.00
| Professional | | $102.00 | $102.00 | $102.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,192.25 / $3,192.25 / $3,192.25
| Professional | | $3,192.25 | $3,192.25 | $3,192.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.42 / $75.63 / $125.18
| Professional | | $50.42 | $75.63 | $125.18 |