- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,547.26 / $1,547.26 / $1,547.26
| Facility | | $1,547.26 | $1,547.26 | $1,547.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.84 / $1,547.26 / $1,547.26
| Professional | | $785.84 | $1,547.26 | $1,547.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,369.97 / $1,369.97 / $1,369.97
| Professional | | $1,369.97 | $1,369.97 | $1,369.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,408.48 / $1,408.48 / $1,998.78
| Facility | | $1,408.48 | $1,408.48 | $1,998.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.19 / $1,408.48 / $1,750.20
| Professional | | $1,028.19 | $1,408.48 | $1,750.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $612.17 / $918.28 / $1,415.04
| Professional | | $612.17 | $918.28 | $1,415.04 |