- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,646.03 / $1,646.03 / $1,646.03
| Facility | | $1,646.03 | $1,646.03 | $1,646.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.62 / $588.62 / $1,646.03
| Professional | | $588.62 | $588.62 | $1,646.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $781.33 / $781.33 / $781.33
| Professional | | $781.33 | $781.33 | $781.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,646.03 / $1,646.03 / $2,765.33
| Facility | | $1,646.03 | $1,646.03 | $2,765.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.00 / $1,853.00 / $1,853.00
| Professional | | $155.00 | $1,853.00 | $1,853.00 |