- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,179.97 / $1,179.97 / $1,203.49
| Facility | | $1,179.97 | $1,179.97 | $1,203.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.32 / $997.63 / $1,371.98
| Professional | | $642.32 | $997.63 | $1,371.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,109.10 / $1,109.10 / $1,190.24
| Professional | | $1,109.10 | $1,109.10 | $1,190.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,281.85 / $2,249.09 / $3,966.29
| Professional | | $1,281.85 | $2,249.09 | $3,966.29 |