- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,131.20 / $1,131.20 / $1,131.20
| Facility | | $1,131.20 | $1,131.20 | $1,131.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $574.52 / $1,131.20 / $1,131.20
| Professional | | $574.52 | $1,131.20 | $1,131.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,001.58 / $1,001.58 / $1,001.58
| Professional | | $1,001.58 | $1,001.58 | $1,001.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.50 / $870.50 / $1,345.68
| Facility | | $870.50 | $870.50 | $1,345.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $635.47 / $870.50 / $1,178.33
| Professional | | $635.47 | $870.50 | $1,178.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $447.56 / $671.35 / $1,034.53
| Professional | | $447.56 | $671.35 | $1,034.53 |