- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,670.58 / $1,670.58 / $1,670.58
| Facility | | $1,670.58 | $1,670.58 | $1,670.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $790.80 / $1,670.58 / $1,670.58
| Professional | | $790.80 | $1,670.58 | $1,670.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,378.63 / $1,378.63 / $1,378.63
| Professional | | $1,378.63 | $1,378.63 | $1,378.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,191.78 / $1,191.78 / $1,842.32
| Facility | | $1,191.78 | $1,191.78 | $1,842.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.00 / $1,191.78 / $1,763.03
| Professional | | $870.00 | $1,191.78 | $1,763.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $547.38 / $821.06 / $1,261.35
| Professional | | $547.38 | $821.06 | $1,261.35 |