- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,365.29 / $1,365.29 / $1,365.29
| Facility | | $1,365.29 | $1,365.29 | $1,365.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.57 / $1,371.43 / $1,604.90
| Professional | | $1,348.57 | $1,371.43 | $1,604.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $150.00
| Professional | | $150.00 | $150.00 | $150.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,466.06 / $1,522.67
| Professional | | $1,000.00 | $1,466.06 | $1,522.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,342.67 / $1,342.67 / $1,342.67
| Professional | | $1,342.67 | $1,342.67 | $1,342.67 |