- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,645.20 / $1,645.20 / $1,645.20
| Facility | | $1,645.20 | $1,645.20 | $1,645.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,375.80 / $1,841.71 / $2,056.50
| Professional | | $1,375.80 | $1,841.71 | $2,056.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.26 / $1,050.26 / $1,541.83
| Professional | | $1,050.26 | $1,050.26 | $1,541.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,371.00 / $1,371.00 / $1,645.20
| Facility | | $1,371.00 | $1,371.00 | $1,645.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $466.14 / $1,096.80 / $1,828.00
| Professional | | $466.14 | $1,096.80 | $1,828.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $383.88 / $932.28 / $1,828.00
| Professional | | $383.88 | $932.28 | $1,828.00 |