- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,053.29 / $1,053.29 / $1,053.29
| Facility | | $1,053.29 | $1,053.29 | $1,053.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.65 / $1,014.96 / $1,053.29
| Professional | | $776.65 | $1,014.96 | $1,053.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $631.22 / $1,039.66 / $1,276.58
| Professional | | $631.22 | $1,039.66 | $1,276.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.16 / $1,276.58 / $1,276.58
| Professional | | $364.16 | $1,276.58 | $1,276.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $679.85 / $1,344.45 / $1,976.38
| Professional | | $679.85 | $1,344.45 | $1,976.38 |