- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,463.85 / $1,463.85 / $1,463.85
| Facility | | $1,463.85 | $1,463.85 | $1,463.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,463.85 / $1,463.85 / $1,463.85
| Professional | | $1,463.85 | $1,463.85 | $1,463.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,936.51 / $3,936.51 / $3,936.51
| Professional | | $3,936.51 | $3,936.51 | $3,936.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.35 / $248.35 / $248.35
| Professional | | $248.35 | $248.35 | $248.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.01 / $266.77 / $468.55
| Professional | | $173.01 | $266.77 | $468.55 |