- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,064.03 / $1,064.03 / $1,064.03
| Facility | | $1,064.03 | $1,064.03 | $1,064.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.68 / $1,064.03 / $1,064.03
| Professional | | $503.68 | $1,064.03 | $1,064.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $781.66 / $781.66 / $781.66
| Professional | | $781.66 | $781.66 | $781.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $736.22 / $736.22 / $1,178.21
| Facility | | $736.22 | $736.22 | $1,178.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.44 / $736.22 / $1,031.68
| Professional | | $537.44 | $736.22 | $1,031.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $391.86 / $587.79 / $885.43
| Professional | | $391.86 | $587.79 | $885.43 |