- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,520.80 / $1,520.80 / $2,376.25
| Facility | | $1,520.80 | $1,520.80 | $2,376.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,425.38 / $2,146.88 / $2,376.25
| Professional | | $1,425.38 | $2,146.88 | $2,376.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,102.94 / $2,102.94 / $2,102.94
| Professional | | $2,102.94 | $2,102.94 | $2,102.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,482.94 / $1,482.94 / $1,482.94
| Facility | | $1,482.94 | $1,482.94 | $1,482.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.50 / $1,260.50 / $1,482.94
| Professional | | $1,260.50 | $1,260.50 | $1,482.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $789.32 / $1,353.86 / $1,845.17
| Professional | | $789.32 | $1,353.86 | $1,845.17 |