- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,452.72 / $1,452.72 / $1,452.72
| Facility | | $1,452.72 | $1,452.72 | $1,452.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $687.68 / $1,452.72 / $1,452.72
| Professional | | $687.68 | $1,452.72 | $1,452.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,198.84 / $1,198.84 / $1,198.84
| Professional | | $1,198.84 | $1,198.84 | $1,198.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,006.48 / $1,006.48 / $1,610.72
| Facility | | $1,006.48 | $1,006.48 | $1,610.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $734.73 / $734.73 / $1,867.50
| Professional | | $734.73 | $734.73 | $1,867.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $820.00 / $820.00 / $820.00
| Facility | | $820.00 | $820.00 | $820.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $535.72 / $803.57 / $1,283.09
| Professional | | $535.72 | $803.57 | $1,283.09 |