- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,587.17 / $2,587.17 / $2,587.17
| Facility | | $2,587.17 | $2,587.17 | $2,587.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $434.01 / $546.40 / $629.32
| Professional | | $434.01 | $546.40 | $629.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $619.79 / $802.21 / $1,285.75
| Professional | | $619.79 | $802.21 | $1,285.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $619.79 / $778.29 / $1,285.75
| Professional | | $619.79 | $778.29 | $1,285.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $641.86 / $976.66 / $1,896.82
| Professional | | $641.86 | $976.66 | $1,896.82 |