- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,531.76 / $1,531.76 / $1,531.76
| Facility | | $1,531.76 | $1,531.76 | $1,531.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $777.96 / $1,531.76 / $1,531.76
| Professional | | $777.96 | $1,531.76 | $1,531.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,356.24 / $1,356.24 / $1,356.24
| Professional | | $1,356.24 | $1,356.24 | $1,356.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,473.53 / $1,473.53 / $2,277.86
| Facility | | $1,473.53 | $1,473.53 | $2,277.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.68 / $1,473.53 / $1,994.57
| Professional | | $1,075.68 | $1,473.53 | $1,994.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $570.98 / $909.07 / $1,380.46
| Professional | | $570.98 | $909.07 | $1,380.46 |