- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,050.05 / $2,050.05 / $2,050.05
| Facility | | $2,050.05 | $2,050.05 | $2,050.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $970.44 / $2,050.05 / $2,050.05
| Professional | | $970.44 | $2,050.05 | $2,050.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,691.79 / $1,691.79 / $1,691.79
| Professional | | $1,691.79 | $1,691.79 | $1,691.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,179.41 / $1,179.41 / $1,887.48
| Facility | | $1,179.41 | $1,179.41 | $1,887.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.97 / $1,179.41 / $1,684.87
| Professional | | $860.97 | $1,179.41 | $1,684.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $627.76 / $963.89 / $1,489.37
| Professional | | $627.76 | $963.89 | $1,489.37 |