- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,254.65 / $1,254.65 / $1,254.65
| Facility | | $1,254.65 | $1,254.65 | $1,254.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,254.65 / $1,254.65 / $1,254.65
| Professional | | $1,254.65 | $1,254.65 | $1,254.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.07 / $1,319.12 / $1,609.08
| Professional | | $1,314.07 | $1,319.12 | $1,609.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $982.72 / $982.72 / $982.72
| Professional | | $982.72 | $982.72 | $982.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,530.01 / $1,530.01 / $4,672.55
| Professional | | $1,530.01 | $1,530.01 | $4,672.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.88 / $1,174.31 / $1,663.61
| Professional | | $782.88 | $1,174.31 | $1,663.61 |