- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,742.30 / $1,742.30 / $1,742.30
| Facility | | $1,742.30 | $1,742.30 | $1,742.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $824.75 / $1,742.30 / $1,742.30
| Professional | | $824.75 | $1,742.30 | $1,742.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,437.82 / $1,437.82 / $1,437.82
| Professional | | $1,437.82 | $1,437.82 | $1,437.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,207.09 / $1,207.09 / $1,931.80
| Facility | | $1,207.09 | $1,207.09 | $1,931.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.18 / $1,207.09 / $1,691.55
| Professional | | $881.18 | $1,207.09 | $1,691.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.50 / $955.16 / $1,451.76
| Professional | | $642.50 | $955.16 | $1,451.76 |