- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,147.63 / $1,147.63 / $1,147.63
| Facility | | $1,147.63 | $1,147.63 | $1,147.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,147.63 / $1,147.63 / $1,147.63
| Professional | | $1,147.63 | $1,147.63 | $1,147.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,154.00 / $1,206.59 / $1,471.83
| Professional | | $1,154.00 | $1,206.59 | $1,471.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.44 / $928.44 / $928.44
| Professional | | $928.44 | $928.44 | $928.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,399.50 / $1,399.50 / $4,274.00
| Professional | | $1,399.50 | $1,399.50 | $4,274.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $716.10 / $1,074.15 / $1,835.92
| Professional | | $716.10 | $1,074.15 | $1,835.92 |