- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,570.35 / $1,570.35 / $1,570.35
| Facility | | $1,570.35 | $1,570.35 | $1,570.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $797.56 / $1,570.35 / $1,570.35
| Professional | | $797.56 | $1,570.35 | $1,570.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,390.41 / $1,390.41 / $1,390.41
| Professional | | $1,390.41 | $1,390.41 | $1,390.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,167.30 / $1,167.30 / $2,418.36
| Facility | | $1,167.30 | $1,167.30 | $2,418.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $852.13 / $1,167.30 / $2,117.60
| Professional | | $852.13 | $1,167.30 | $2,117.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $621.32 / $931.98 / $1,436.15
| Professional | | $621.32 | $931.98 | $1,436.15 |