- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,273.40 / $1,273.40 / $1,273.40
| Facility | | $1,273.40 | $1,273.40 | $1,273.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,273.40 / $1,273.40 / $1,273.40
| Professional | | $1,273.40 | $1,273.40 | $1,273.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,340.74 / $1,340.74 / $1,340.74
| Professional | | $1,340.74 | $1,340.74 | $1,340.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $997.41 / $997.41 / $997.41
| Professional | | $997.41 | $997.41 | $997.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,552.87 / $1,552.87 / $4,742.37
| Professional | | $1,552.87 | $1,552.87 | $4,742.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.58 / $1,191.85 / $1,688.47
| Professional | | $794.58 | $1,191.85 | $1,688.47 |