- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.28 / $1,737.28 / $1,737.28
| Facility | | $1,737.28 | $1,737.28 | $1,737.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $822.37 / $1,737.28 / $1,737.28
| Professional | | $822.37 | $1,737.28 | $1,737.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,276.26 / $1,276.26 / $1,276.26
| Professional | | $1,276.26 | $1,276.26 | $1,276.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,172.51 / $1,172.51 / $1,998.06
| Facility | | $1,172.51 | $1,172.51 | $1,998.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.93 / $1,172.51 / $1,749.57
| Professional | | $855.93 | $1,172.51 | $1,749.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $624.09 / $936.14 / $1,508.87
| Professional | | $624.09 | $936.14 | $1,508.87 |