- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,350.35 / $2,350.35 / $2,350.35
| Facility | | $2,350.35 | $2,350.35 | $2,350.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,350.35 / $2,350.35 / $2,350.35
| Professional | | $2,350.35 | $2,350.35 | $2,350.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,007.00 / $3,007.00 / $3,007.00
| Professional | | $3,007.00 | $3,007.00 | $3,007.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,342.58 / $1,342.58 / $1,342.58
| Professional | | $1,342.58 | $1,342.58 | $1,342.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.68 / $170.78 / $1,697.43
| Professional | | $110.68 | $170.78 | $1,697.43 |