- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,340.56 / $1,340.56 / $1,340.56
| Facility | | $1,340.56 | $1,340.56 | $1,340.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $680.85 / $1,340.56 / $1,340.56
| Professional | | $680.85 | $1,340.56 | $1,340.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,186.96 / $1,186.96 / $1,186.96
| Professional | | $1,186.96 | $1,186.96 | $1,186.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,020.64 / $1,020.64 / $2,126.34
| Facility | | $1,020.64 | $1,020.64 | $2,126.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $745.07 / $1,020.64 / $1,861.90
| Professional | | $745.07 | $1,020.64 | $1,861.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.40 / $795.61 / $1,258.38
| Professional | | $530.40 | $795.61 | $1,258.38 |