- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,373.42 / $1,373.42 / $1,373.42
| Facility | | $1,373.42 | $1,373.42 | $1,373.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $697.54 / $1,373.42 / $1,373.42
| Professional | | $697.54 | $1,373.42 | $1,373.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,216.05 / $1,216.05 / $1,216.05
| Professional | | $1,216.05 | $1,216.05 | $1,216.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,018.60 / $1,018.60 / $1,773.59
| Facility | | $1,018.60 | $1,018.60 | $1,773.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.58 / $743.58 / $2,056.13
| Professional | | $743.58 | $743.58 | $2,056.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $542.16 / $815.11 / $1,253.19
| Professional | | $542.16 | $815.11 | $1,253.19 |