- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,435.25 / $1,435.25 / $1,435.25
| Facility | | $1,435.25 | $1,435.25 | $1,435.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,361.01 / $1,546.61
| Professional | | $1,237.28 | $1,361.01 | $1,546.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,531.57 / $2,139.69
| Facility | | $1,237.28 | $1,531.57 | $2,139.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,237.28 / $1,237.28
| Professional | | $1,237.28 | $1,237.28 | $1,237.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $45.00 / $60.00
| Professional | | $30.00 | $45.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.91 / $1,361.01 / $1,361.01
| Professional | | $1,224.91 | $1,361.01 | $1,361.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,237.28 / $1,237.28
| Professional | | $1,237.28 | $1,237.28 | $1,237.28 |