- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,524.87 / $1,524.87 / $1,742.70
| Facility | | $1,524.87 | $1,524.87 | $1,742.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,524.87 / $1,742.70
| Professional | | $1,452.25 | $1,524.87 | $1,742.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,452.25
| Facility | | $1,452.25 | $1,452.25 | $1,452.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,452.25
| Professional | | $1,452.25 | $1,452.25 | $1,452.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,379.64 / $1,452.25 / $1,887.93
| Professional | | $1,379.64 | $1,452.25 | $1,887.93 |