- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,407.07 / $1,407.07 / $1,407.07
| Facility | | $1,407.07 | $1,407.07 | $1,407.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,231.19 / $1,407.07
| Professional | | $1,172.56 | $1,231.19 | $1,407.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,264.33 / $1,264.33 / $1,264.33
| Facility | | $1,264.33 | $1,264.33 | $1,264.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.50 / $1,264.33 / $1,264.33
| Professional | | $1,237.50 | $1,264.33 | $1,264.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,106.19 / $1,172.56 / $1,172.56
| Facility | | $1,106.19 | $1,172.56 | $1,172.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,172.56 / $1,272.10
| Professional | | $1,172.56 | $1,172.56 | $1,272.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,078.76 / $1,172.56 / $1,196.01
| Professional | | $1,078.76 | $1,172.56 | $1,196.01 |