- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,831.50 / $1,831.50 / $1,831.50
| Facility | | $1,831.50 | $1,831.50 | $1,831.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,831.50 / $2,671.41 / $2,706.40
| Professional | | $1,831.50 | $2,671.41 | $2,706.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.98 / $1,751.98 / $2,249.50
| Professional | | $1,751.98 | $1,751.98 | $2,249.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.88 / $1,472.88 / $1,472.88
| Professional | | $1,472.88 | $1,472.88 | $1,472.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.77 / $218.57 / $2,122.05
| Professional | | $156.77 | $218.57 | $2,122.05 |