- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,726.72 / $1,726.72 / $1,726.72
| Facility | | $1,726.72 | $1,726.72 | $1,726.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,726.72 / $1,726.72 / $3,135.93
| Professional | | $1,726.72 | $1,726.72 | $3,135.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,216.35 / $1,648.48 / $3,094.62
| Facility | | $1,216.35 | $1,648.48 | $3,094.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,554.05 / $2,873.26 / $3,280.77
| Facility | | $1,554.05 | $2,873.26 | $3,280.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $447.50 / $447.50 / $447.50
| Professional | | $447.50 | $447.50 | $447.50 |