- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,009.06 / $1,009.06 / $1,009.06
| Facility | | $1,009.06 | $1,009.06 | $1,009.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,009.06 / $1,009.06 / $1,009.06
| Professional | | $1,009.06 | $1,009.06 | $1,009.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.00 / $1,060.91 / $1,294.11
| Professional | | $1,015.00 | $1,060.91 | $1,294.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.20 / $1,094.20 / $1,094.20
| Professional | | $1,094.20 | $1,094.20 | $1,094.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.52 / $1,230.52 / $3,757.93
| Professional | | $1,230.52 | $1,230.52 | $3,757.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $629.63 / $944.45 / $1,337.97
| Professional | | $629.63 | $944.45 | $1,337.97 |