- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,058.50 / $2,058.50 / $2,058.50
| Facility | | $2,058.50 | $2,058.50 | $2,058.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,058.50 / $2,058.50 / $3,859.68
| Professional | | $2,058.50 | $2,058.50 | $3,859.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,421.83 / $1,594.15 / $1,736.86
| Facility | | $1,421.83 | $1,594.15 | $1,736.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $791.99 / $1,543.87 / $1,543.87
| Professional | | $791.99 | $1,543.87 | $1,543.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.85 / $1,509.22 / $2,151.11
| Professional | | $1,040.85 | $1,509.22 | $2,151.11 |