- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,152.39 / $1,152.39 / $1,152.39
| Facility | | $1,152.39 | $1,152.39 | $1,152.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.28 / $1,152.39 / $1,152.39
| Professional | | $585.28 | $1,152.39 | $1,152.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,020.35 / $1,020.35 / $1,020.35
| Professional | | $1,020.35 | $1,020.35 | $1,020.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $809.08 / $809.08 / $1,376.84
| Facility | | $809.08 | $809.08 | $1,376.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $687.72 / $809.08 / $1,304.84
| Professional | | $687.72 | $809.08 | $1,304.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $430.65 / $683.93 / $995.42
| Professional | | $430.65 | $683.93 | $995.42 |