- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,080.97 / $1,080.97 / $1,080.97
| Facility | | $1,080.97 | $1,080.97 | $1,080.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.97 / $1,080.97 / $1,080.97
| Professional | | $1,080.97 | $1,080.97 | $1,080.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,416.00 / $1,416.00 / $1,416.00
| Professional | | $1,416.00 | $1,416.00 | $1,416.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,196.32 / $1,196.32 / $1,196.32
| Professional | | $1,196.32 | $1,196.32 | $1,196.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,716.75 / $1,716.75 / $5,242.84
| Professional | | $1,716.75 | $1,716.75 | $5,242.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $878.43 / $1,317.65 / $2,050.96
| Professional | | $878.43 | $1,317.65 | $2,050.96 |