- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,342.10 / $1,342.10 / $1,342.10
| Facility | | $1,342.10 | $1,342.10 | $1,342.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $681.63 / $1,342.10 / $1,342.10
| Professional | | $681.63 | $1,342.10 | $1,342.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $955.63 / $955.63 / $955.63
| Professional | | $955.63 | $955.63 | $955.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $950.52 / $950.52 / $1,587.98
| Facility | | $950.52 | $950.52 | $1,587.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $693.88 / $950.52 / $1,390.49
| Professional | | $693.88 | $950.52 | $1,390.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $471.92 / $796.51 / $1,096.53
| Professional | | $471.92 | $796.51 | $1,096.53 |