- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,540.50 / $1,540.50 / $1,540.50
| Facility | | $1,540.50 | $1,540.50 | $1,540.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,540.50 / $1,540.50 / $2,069.05
| Professional | | $1,540.50 | $1,540.50 | $2,069.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,101.23 / $2,101.23 / $2,572.98
| Professional | | $2,101.23 | $2,101.23 | $2,572.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.53 / $1,698.53 / $1,698.53
| Professional | | $1,698.53 | $1,698.53 | $1,698.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,446.55 / $2,446.55 / $7,471.60
| Professional | | $2,446.55 | $2,446.55 | $7,471.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,251.84 / $1,877.77 / $2,821.35
| Professional | | $1,251.84 | $1,877.77 | $2,821.35 |