- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,772.04 / $1,772.04 / $2,516.05
| Facility | | $1,772.04 | $1,772.04 | $2,516.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,145.06 / $1,145.06 / $1,409.05
| Professional | | $1,145.06 | $1,145.06 | $1,409.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.86 / $520.86 / $520.86
| Professional | | $520.86 | $520.86 | $520.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $1,082.35 / $1,082.35
| Professional | | $150.00 | $1,082.35 | $1,082.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,002.40 / $1,145.06 / $2,028.99
| Facility | | $1,002.40 | $1,145.06 | $2,028.99 |