- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,083.33 / $1,083.33 / $1,083.33
| Facility | | $1,083.33 | $1,083.33 | $1,083.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,083.33 / $1,083.33 / $1,083.33
| Professional | | $1,083.33 | $1,083.33 | $1,083.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,252.48 / $1,252.48 / $1,252.48
| Professional | | $1,252.48 | $1,252.48 | $1,252.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $988.28 / $988.28 / $988.28
| Professional | | $988.28 | $988.28 | $988.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,321.10 / $1,321.10 / $4,034.54
| Professional | | $1,321.10 | $1,321.10 | $4,034.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $675.98 / $1,013.97 / $1,436.46
| Professional | | $675.98 | $1,013.97 | $1,436.46 |