- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,742.67 / $1,742.67 / $1,742.67
| Facility | | $1,742.67 | $1,742.67 | $1,742.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $885.08 / $1,742.67 / $1,742.67
| Professional | | $885.08 | $1,742.67 | $1,742.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,373.56 / $1,373.56 / $1,373.56
| Professional | | $1,373.56 | $1,373.56 | $1,373.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,295.39 / $1,295.39 / $2,505.05
| Facility | | $1,295.39 | $1,295.39 | $2,505.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $945.63 / $1,295.39 / $2,193.51
| Professional | | $945.63 | $1,295.39 | $2,193.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $689.50 / $1,034.25 / $1,593.75
| Professional | | $689.50 | $1,034.25 | $1,593.75 |