- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,085.77 / $1,085.77 / $1,085.77
| Facility | | $1,085.77 | $1,085.77 | $1,085.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.77 / $1,085.77 / $1,085.77
| Professional | | $1,085.77 | $1,085.77 | $1,085.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,950.00 / $1,950.00 / $1,950.00
| Facility | | $1,950.00 | $1,950.00 | $1,950.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.82 / $1,950.00 / $3,611.25
| Professional | | $244.82 | $1,950.00 | $3,611.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.51 / $186.06 / $294.98
| Professional | | $105.51 | $186.06 | $294.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,210.33 / $1,253.32 / $1,981.64
| Professional | | $1,210.33 | $1,253.32 | $1,981.64 |