- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,375.15 / $1,375.15 / $1,375.15
| Facility | | $1,375.15 | $1,375.15 | $1,375.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,375.15 / $1,375.15 / $1,375.15
| Professional | | $1,375.15 | $1,375.15 | $1,375.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,429.07 / $1,429.07 / $1,429.07
| Professional | | $1,429.07 | $1,429.07 | $1,429.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,429.07 / $1,429.07 / $1,429.07
| Facility | | $1,429.07 | $1,429.07 | $1,429.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,370.18 / $1,370.18 / $1,370.18
| Professional | | $1,370.18 | $1,370.18 | $1,370.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.65 / $1,388.63 / $2,250.66
| Professional | | $1,263.65 | $1,388.63 | $2,250.66 |