- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,134.36 / $1,134.36 / $1,134.36
| Facility | | $1,134.36 | $1,134.36 | $1,134.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $536.98 / $1,134.36 / $1,134.36
| Professional | | $536.98 | $1,134.36 | $1,134.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $936.13 / $936.13 / $936.13
| Professional | | $936.13 | $936.13 | $936.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $755.39 / $755.39 / $1,502.44
| Facility | | $755.39 | $755.39 | $1,502.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $551.42 / $755.39 / $1,315.59
| Professional | | $551.42 | $755.39 | $1,315.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.07 / $603.10 / $908.49
| Professional | | $402.07 | $603.10 | $908.49 |