- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,175.33 / $1,175.33 / $1,175.33
| Facility | | $1,175.33 | $1,175.33 | $1,175.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $556.37 / $1,175.33 / $1,175.33
| Professional | | $556.37 | $1,175.33 | $1,175.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $969.94 / $969.94 / $969.94
| Professional | | $969.94 | $969.94 | $969.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $723.52 / $723.52 / $1,296.14
| Facility | | $723.52 | $723.52 | $1,296.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $528.16 / $723.52 / $1,134.94
| Professional | | $528.16 | $723.52 | $1,134.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $385.10 / $577.66 / $895.02
| Professional | | $385.10 | $577.66 | $895.02 |