- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,697.29 / $1,697.29 / $1,697.29
| Facility | | $1,697.29 | $1,697.29 | $1,697.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $803.44 / $1,697.29 / $1,697.29
| Professional | | $803.44 | $1,697.29 | $1,697.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,167.93 / $1,167.93 / $1,167.93
| Professional | | $1,167.93 | $1,167.93 | $1,167.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.46 / $1,277.46 / $2,076.54
| Facility | | $1,277.46 | $1,277.46 | $2,076.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.55 / $1,277.46 / $1,818.29
| Professional | | $932.55 | $1,277.46 | $1,818.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $625.90 / $938.86 / $1,436.70
| Professional | | $625.90 | $938.86 | $1,436.70 |