- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,491.83 / $1,491.83 / $1,491.83
| Facility | | $1,491.83 | $1,491.83 | $1,491.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $757.68 / $1,491.83 / $1,491.83
| Professional | | $757.68 | $1,491.83 | $1,491.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,320.89 / $1,320.89 / $1,320.89
| Professional | | $1,320.89 | $1,320.89 | $1,320.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,530.70 / $1,530.70 / $2,366.26
| Facility | | $1,530.70 | $1,530.70 | $2,366.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.41 / $1,117.41 / $2,743.13
| Professional | | $1,117.41 | $1,117.41 | $2,743.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $590.25 / $885.38 / $1,400.37
| Professional | | $590.25 | $885.38 | $1,400.37 |