- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,155.14 / $1,155.14 / $1,155.14
| Facility | | $1,155.14 | $1,155.14 | $1,155.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $586.67 / $1,155.14 / $1,155.14
| Professional | | $586.67 | $1,155.14 | $1,155.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,022.78 / $1,022.78 / $1,022.78
| Professional | | $1,022.78 | $1,022.78 | $1,022.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,036.33 / $1,036.33 / $1,602.03
| Facility | | $1,036.33 | $1,036.33 | $1,602.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $756.53 / $1,036.33 / $1,402.79
| Professional | | $756.53 | $1,036.33 | $1,402.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.04 / $685.56 / $1,104.98
| Professional | | $457.04 | $685.56 | $1,104.98 |