- 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 / $3,511.89
| Professional | | $1,463.85 | $1,463.85 | $3,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.35 / $248.35 / $6,067.50
| Professional | | $248.35 | $248.35 | $6,067.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $475.33
| Professional | | $60.00 | $60.00 | $475.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.74 / $226.76 / $2,147.04
| Professional | | $204.74 | $226.76 | $2,147.04 |