- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,137.41 / $1,137.41 / $1,137.41
| Facility | | $1,137.41 | $1,137.41 | $1,137.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,137.41 / $1,137.41 / $1,137.41
| Professional | | $1,137.41 | $1,137.41 | $1,137.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,740.40 / $2,262.52 / $2,262.52
| Professional | | $1,740.40 | $2,262.52 | $2,262.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,370.14 / $1,370.14 / $4,062.13
| Professional | | $1,370.14 | $1,370.14 | $4,062.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $809.33 / $1,353.69 / $1,946.36
| Professional | | $809.33 | $1,353.69 | $1,946.36 |