- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,700.15 / $1,700.15 / $1,700.15
| Facility | | $1,700.15 | $1,700.15 | $1,700.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,700.15 / $1,700.15 / $1,700.15
| Professional | | $1,700.15 | $1,700.15 | $1,700.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,078.40 / $2,558.90 / $2,558.90
| Professional | | $2,078.40 | $2,558.90 | $2,558.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,342.58 / $1,342.58 / $1,342.58
| Professional | | $1,342.58 | $1,342.58 | $1,342.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.31 / $145.25 / $333.36
| Professional | | $94.31 | $145.25 | $333.36 |