- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,658.61 / $1,658.61 / $1,658.61
| Facility | | $1,658.61 | $1,658.61 | $1,658.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.14 / $1,658.61 / $1,658.61
| Professional | | $785.14 | $1,658.61 | $1,658.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,368.76 / $1,368.76 / $1,368.76
| Professional | | $1,368.76 | $1,368.76 | $1,368.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,108.41 / $1,108.41 / $2,032.83
| Facility | | $1,108.41 | $1,108.41 | $2,032.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $809.14 / $1,108.41 / $1,780.02
| Professional | | $809.14 | $1,108.41 | $1,780.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $581.04 / $871.57 / $1,312.90
| Professional | | $581.04 | $871.57 | $1,312.90 |