- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,164.52 / $1,164.52 / $1,164.52
| Facility | | $1,164.52 | $1,164.52 | $1,164.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,164.52 / $1,164.52 / $1,164.52
| Professional | | $1,164.52 | $1,164.52 | $1,164.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,171.00 / $1,171.00 / $1,171.00
| Professional | | $1,171.00 | $1,171.00 | $1,171.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $945.63 / $945.63 / $945.63
| Professional | | $945.63 | $945.63 | $945.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,420.11 / $1,420.11 / $4,336.91
| Professional | | $1,420.11 | $1,420.11 | $4,336.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $726.64 / $1,089.96 / $1,862.95
| Professional | | $726.64 | $1,089.96 | $1,862.95 |