- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,374.50 / $1,374.50 / $1,374.50
| Facility | | $1,374.50 | $1,374.50 | $1,374.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.73 / $1,374.50 / $1,502.32
| Professional | | $1,214.73 | $1,374.50 | $1,502.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,220.20 / $1,220.20 / $1,382.95
| Professional | | $1,220.20 | $1,220.20 | $1,382.95 |
- 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
- $341.57 / $954.10 / $1,459.20
| Professional | | $341.57 | $954.10 | $1,459.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $653.03 / $952.83 / $1,278.47
| Professional | | $653.03 | $952.83 | $1,278.47 |