- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,143.26 / $1,143.26 / $1,143.26
| Facility | | $1,143.26 | $1,143.26 | $1,143.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.17 / $1,143.26 / $1,143.26
| Professional | | $541.17 | $1,143.26 | $1,143.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $857.35 / $857.35 / $857.35
| Professional | | $857.35 | $857.35 | $857.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.89 / $741.89 / $1,260.75
| Facility | | $741.89 | $741.89 | $1,260.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.58 / $741.89 / $1,237.90
| Professional | | $541.58 | $741.89 | $1,237.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $374.59 / $561.89 / $897.18
| Professional | | $374.59 | $561.89 | $897.18 |