- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,885.15 / $1,885.15 / $1,885.15
| Facility | | $1,885.15 | $1,885.15 | $1,885.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $892.37 / $1,885.15 / $1,885.15
| Professional | | $892.37 | $1,885.15 | $1,885.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,441.32 / $1,441.32 / $1,441.32
| Professional | | $1,441.32 | $1,441.32 | $1,441.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,306.07 / $1,306.07 / $2,233.75
| Facility | | $1,306.07 | $1,306.07 | $2,233.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $953.43 / $1,306.07 / $1,955.95
| Professional | | $953.43 | $1,306.07 | $1,955.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $695.18 / $1,042.77 / $1,570.79
| Professional | | $695.18 | $1,042.77 | $1,570.79 |