- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,019.23 / $1,019.23 / $1,019.23
| Facility | | $1,019.23 | $1,019.23 | $1,019.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,019.23 / $1,019.23 / $1,019.23
| Professional | | $1,019.23 | $1,019.23 | $1,019.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,716.70 / $1,716.70 / $1,716.70
| Professional | | $1,716.70 | $1,716.70 | $1,716.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,359.37 / $1,359.37 / $3,640.06
| Professional | | $1,359.37 | $1,359.37 | $3,640.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $725.24 / $1,213.03 / $1,897.12
| Professional | | $725.24 | $1,213.03 | $1,897.12 |