- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,030.75 / $1,030.75 / $1,030.75
| Facility | | $1,030.75 | $1,030.75 | $1,030.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,030.75 / $1,030.75 / $1,030.75
| Professional | | $1,030.75 | $1,030.75 | $1,030.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,037.00 / $1,037.00 / $1,321.94
| Professional | | $1,037.00 | $1,037.00 | $1,321.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $895.54 / $895.54 / $895.54
| Professional | | $895.54 | $895.54 | $895.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,256.97 / $1,256.97 / $3,838.71
| Professional | | $1,256.97 | $1,256.97 | $3,838.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $643.16 / $964.75 / $1,366.73
| Professional | | $643.16 | $964.75 | $1,366.73 |