- 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 / $1,751.72
| Professional | | $1,751.72 | $1,751.72 | $1,751.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,844.50 / $1,844.50 / $1,844.50
| Professional | | $1,844.50 | $1,844.50 | $1,844.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.38 / $1,202.38 / $1,202.38
| Professional | | $1,202.38 | $1,202.38 | $1,202.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $783.67 / $783.67 / $783.67
| Professional | | $783.67 | $783.67 | $783.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,751.72 / $1,751.72 / $1,979.44
| Facility | | $1,751.72 | $1,751.72 | $1,979.44 |