- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,751.72 / $1,751.72 / $1,751.72
| Facility | | $1,751.72 | $1,751.72 | $1,751.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.72 / $1,751.72 / $2,411.21
| Professional | | $1,751.72 | $1,751.72 | $2,411.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.47 / $184.45 / $184.45
| Facility | | $166.47 | $184.45 | $184.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,637.59 / $1,844.50 / $1,844.50
| Professional | | $1,637.59 | $1,844.50 | $1,844.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,080.00 / $1,080.00 / $1,080.00
| Facility | | $1,080.00 | $1,080.00 | $1,080.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $783.67 / $783.67 / $783.67
| Professional | | $783.67 | $783.67 | $783.67 |