- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,601.06 / $1,601.06 / $1,601.06
| Facility | | $1,601.06 | $1,601.06 | $1,601.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $813.16 / $1,601.06 / $1,601.06
| Professional | | $813.16 | $1,601.06 | $1,601.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,417.60 / $1,417.60 / $1,417.60
| Professional | | $1,417.60 | $1,417.60 | $1,417.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,551.30 / $1,551.30 / $2,398.11
| Facility | | $1,551.30 | $1,551.30 | $2,398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,132.45 / $1,551.30 / $2,099.86
| Professional | | $1,132.45 | $1,551.30 | $2,099.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $633.47 / $950.20 / $1,517.23
| Professional | | $633.47 | $950.20 | $1,517.23 |