- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,448.01 / $1,448.01 / $1,448.01
| Facility | | $1,448.01 | $1,448.01 | $1,448.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $787.48 / $1,403.78 / $1,448.01
| Professional | | $787.48 | $1,403.78 | $1,448.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,383.80 / $1,383.80 / $1,383.80
| Professional | | $1,383.80 | $1,383.80 | $1,383.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.47 / $1,122.47 / $1,459.20
| Facility | | $1,122.47 | $1,122.47 | $1,459.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.82 / $1,122.47 / $2,077.50
| Professional | | $140.82 | $1,122.47 | $2,077.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $852.22 / $1,540.24
| Professional | | $588.84 | $852.22 | $1,540.24 |