- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,745.20 / $1,745.20 / $1,745.20
| Facility | | $1,745.20 | $1,745.20 | $1,745.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $826.13 / $1,745.20 / $1,745.20
| Professional | | $826.13 | $1,745.20 | $1,745.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,440.21 / $1,440.21 / $1,440.21
| Professional | | $1,440.21 | $1,440.21 | $1,440.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,206.80 / $1,206.80 / $2,575.08
| Facility | | $1,206.80 | $1,206.80 | $2,575.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.96 / $1,206.80 / $2,254.83
| Professional | | $880.96 | $1,206.80 | $2,254.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.34 / $963.51 / $1,538.47
| Professional | | $642.34 | $963.51 | $1,538.47 |