- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,232.55 / $2,908.08 / $3,419.96
| Facility | | $1,232.55 | $2,908.08 | $3,419.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,232.55 / $1,262.25 / $1,262.25
| Professional | | $1,232.55 | $1,262.25 | $1,262.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,311.75 / $1,311.75 / $1,311.75
| Facility | | $1,311.75 | $1,311.75 | $1,311.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.50 / $1,262.25 / $1,262.25
| Professional | | $1,237.50 | $1,262.25 | $1,262.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.95 / $1,262.25 / $1,670.63
| Professional | | $5.95 | $1,262.25 | $1,670.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,485.00 / $1,485.00 / $1,485.00
| Professional | | $1,485.00 | $1,485.00 | $1,485.00 |