- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,406.60 / $1,406.60 / $1,406.60
| Facility | | $1,406.60 | $1,406.60 | $1,406.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $735.78 / $1,169.36 / $1,406.60
| Professional | | $735.78 | $1,169.36 | $1,406.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,284.27 / $1,284.27 / $2,030.00
| Professional | | $1,284.27 | $1,284.27 | $2,030.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.11 / $93.11 / $109.54
| Professional | | $93.11 | $93.11 | $109.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.20 / $88.38 / $773.16
| Professional | | $67.20 | $88.38 | $773.16 |