- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,007.42 / $1,007.42 / $1,007.42
| Facility | | $1,007.42 | $1,007.42 | $1,007.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $983.72 / $1,007.42 / $1,007.42
| Professional | | $983.72 | $1,007.42 | $1,007.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $987.67 / $987.67 / $987.67
| Facility | | $987.67 | $987.67 | $987.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $987.67 / $987.67 / $987.67
| Professional | | $987.67 | $987.67 | $987.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,046.93 / $1,046.93 / $1,086.44
| Facility | | $1,046.93 | $1,046.93 | $1,086.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,046.93 / $1,046.93 / $1,046.93
| Professional | | $1,046.93 | $1,046.93 | $1,046.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,068.81 / $1,185.20 / $1,185.20
| Professional | | $1,068.81 | $1,185.20 | $1,185.20 |