- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,448.30 / $1,448.30 / $1,448.30
| Facility | | $1,448.30 | $1,448.30 | $1,448.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,448.30 / $1,448.30 / $2,237.34
| Professional | | $1,448.30 | $1,448.30 | $2,237.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.69 / $214.85 / $350.00
| Professional | | $79.69 | $214.85 | $350.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,686.90 / $1,792.59 / $2,240.08
| Facility | | $1,686.90 | $1,792.59 | $2,240.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.37 / $198.37 / $198.37
| Professional | | $198.37 | $198.37 | $198.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $550.83 / $550.83 / $640.14
| Professional | | $550.83 | $550.83 | $640.14 |