- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,285.81 / $1,285.81 / $1,285.81
| Facility | | $1,285.81 | $1,285.81 | $1,285.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,285.81 / $1,285.81 / $1,285.81
| Professional | | $1,285.81 | $1,285.81 | $1,285.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,389.60 / $2,412.83 / $2,412.83
| Professional | | $2,389.60 | $2,412.83 | $2,412.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,413.48 / $2,413.48 / $4,592.10
| Professional | | $2,413.48 | $2,413.48 | $4,592.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $914.92 / $1,530.31 / $2,060.65
| Professional | | $914.92 | $1,530.31 | $2,060.65 |