- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,217.70 / $1,217.70 / $1,782.00
| Facility | | $1,217.70 | $1,217.70 | $1,782.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,217.70 / $1,485.00 / $1,782.00
| Professional | | $1,217.70 | $1,485.00 | $1,782.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,113.75 / $1,113.75 / $1,113.75
| Facility | | $1,113.75 | $1,113.75 | $1,113.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.15 / $51.15 / $51.15
| Professional | | $51.15 | $51.15 | $51.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,262.25 / $1,262.25 / $1,262.25
| Professional | | $1,262.25 | $1,262.25 | $1,262.25 |