- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,369.36 / $1,369.36 / $1,369.36
| Facility | | $1,369.36 | $1,369.36 | $1,369.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $695.48 / $1,369.36 / $1,369.36
| Professional | | $695.48 | $1,369.36 | $1,369.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,212.46 / $1,212.46 / $1,212.46
| Professional | | $1,212.46 | $1,212.46 | $1,212.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $926.75 / $926.75 / $1,661.69
| Facility | | $926.75 | $926.75 | $1,661.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $787.74 / $787.74 / $1,926.38
| Professional | | $787.74 | $787.74 | $1,926.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $493.28 / $812.69 / $1,140.19
| Professional | | $493.28 | $812.69 | $1,140.19 |