- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,436.52 / $1,436.52 / $1,436.52
| Facility | | $1,436.52 | $1,436.52 | $1,436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,436.52 / $1,436.52 / $1,436.52
| Professional | | $1,436.52 | $1,436.52 | $1,436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.10 / $1,510.34 / $1,842.34
| Professional | | $1,445.10 | $1,510.34 | $1,842.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,303.96 / $1,303.96 / $1,303.96
| Professional | | $1,303.96 | $1,303.96 | $1,303.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.80 / $1,751.80 / $5,349.88
| Professional | | $1,751.80 | $1,751.80 | $5,349.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $896.36 / $1,344.55 / $1,904.77
| Professional | | $896.36 | $1,344.55 | $1,904.77 |