- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $128.82 / $128.82
| Facility | | $128.82 | $128.82 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,659.59
| Professional | | $1,412.54 | $1,412.54 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,737.80 / $1,737.80
| Professional | | $1,479.11 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $1,348.96
| Facility | | $1,348.96 | $1,348.96 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,698.24 / $2,041.74
| Professional | | $1,412.54 | $1,698.24 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $1,380.38 / $1,445.44
| Professional | | $125.89 | $1,380.38 | $1,445.44 |