- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,201.95 / $1,201.95 / $1,201.95
| Facility | | $1,201.95 | $1,201.95 | $1,201.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.05 / $124.05 / $1,056.08
| Professional | | $124.05 | $124.05 | $1,056.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,711.70 / $2,711.70 / $2,839.48
| Professional | | $2,711.70 | $2,711.70 | $2,839.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.78 / $147.78 / $147.78
| Professional | | $147.78 | $147.78 | $147.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $654.01 / $1,201.95 / $1,231.02
| Professional | | $654.01 | $1,201.95 | $1,231.02 |