- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,297.56 / $1,297.56 / $1,297.56
| Facility | | $1,297.56 | $1,297.56 | $1,297.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $659.01 / $1,297.56 / $1,297.56
| Professional | | $659.01 | $1,297.56 | $1,297.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.88 / $1,148.88 / $1,148.88
| Professional | | $1,148.88 | $1,148.88 | $1,148.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,260.83 / $1,260.83 / $1,789.26
| Facility | | $1,260.83 | $1,260.83 | $1,789.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $920.41 / $1,260.83 / $1,566.73
| Professional | | $920.41 | $1,260.83 | $1,566.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $513.39 / $770.08 / $1,186.67
| Professional | | $513.39 | $770.08 | $1,186.67 |