- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,547.10 / $1,547.10 / $1,547.10
| Facility | | $1,547.10 | $1,547.10 | $1,547.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.75 / $1,547.10 / $1,547.10
| Professional | | $785.75 | $1,547.10 | $1,547.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,369.83 / $1,369.83 / $1,369.83
| Professional | | $1,369.83 | $1,369.83 | $1,369.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,022.07 / $1,022.07 / $1,830.52
| Facility | | $1,022.07 | $1,022.07 | $1,830.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.76 / $1,022.07 / $1,602.87
| Professional | | $868.76 | $1,022.07 | $1,602.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $544.02 / $918.18 / $1,264.03
| Professional | | $544.02 | $918.18 | $1,264.03 |