- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,923.46 / $1,923.46 / $1,923.46
| Facility | | $1,923.46 | $1,923.46 | $1,923.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $551.89 / $760.75 / $1,219.28
| Professional | | $551.89 | $760.75 | $1,219.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.49 / $1,132.75 / $1,569.32
| Professional | | $604.49 | $1,132.75 | $1,569.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $662.72 / $925.71 / $1,974.59
| Professional | | $662.72 | $925.71 | $1,974.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $827.59 / $1,028.16 / $1,563.83
| Professional | | $827.59 | $1,028.16 | $1,563.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.82 / $845.79 / $1,835.33
| Professional | | $602.82 | $845.79 | $1,835.33 |