- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,741.67 / $1,741.67 / $1,741.67
| Facility | | $1,741.67 | $1,741.67 | $1,741.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $824.46 / $1,741.67 / $1,741.67
| Professional | | $824.46 | $1,741.67 | $1,741.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,437.30 / $1,437.30 / $1,437.30
| Professional | | $1,437.30 | $1,437.30 | $1,437.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,107.01 / $1,107.01 / $2,327.96
| Facility | | $1,107.01 | $1,107.01 | $2,327.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $808.12 / $1,107.01 / $2,038.45
| Professional | | $808.12 | $1,107.01 | $2,038.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $589.23 / $883.84 / $1,331.38
| Professional | | $589.23 | $883.84 | $1,331.38 |