- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,513.56
| Facility | | $1,513.56 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,584.89 / $3,467.37
| Professional | | $1,258.93 | $1,584.89 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,659.59 / $2,344.23
| Professional | | $1,348.96 | $1,659.59 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Facility | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $2,089.30
| Professional | | $933.25 | $1,318.26 | $2,089.30 |