- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,360.17 / $1,360.17 / $1,360.17
| Facility | | $1,360.17 | $1,360.17 | $1,360.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,289.81 / $1,465.70
| Professional | | $1,172.56 | $1,289.81 | $1,465.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.65 / $1,389.38 / $2,837.25
| Facility | | $140.65 | $1,389.38 | $2,837.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,172.56 / $1,172.56
| Professional | | $1,172.56 | $1,172.56 | $1,172.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,172.56 / $1,172.56
| Professional | | $1,172.56 | $1,172.56 | $1,172.56 |