- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,685.93 / $1,685.93 / $1,685.93
| Facility | | $1,685.93 | $1,685.93 | $1,685.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $856.26 / $1,685.93 / $1,685.93
| Professional | | $856.26 | $1,685.93 | $1,685.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,492.75 / $1,492.75 / $1,492.75
| Professional | | $1,492.75 | $1,492.75 | $1,492.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,576.65 / $1,576.65 / $2,437.29
| Facility | | $1,576.65 | $1,576.65 | $2,437.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,150.95 / $1,576.65 / $2,134.17
| Professional | | $1,150.95 | $1,576.65 | $2,134.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $624.00 / $1,000.57 / $1,442.35
| Professional | | $624.00 | $1,000.57 | $1,442.35 |