- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,485.70 / $1,485.70 / $1,485.70
| Facility | | $1,485.70 | $1,485.70 | $1,485.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,485.70 / $1,675.56 / $1,873.63
| Professional | | $1,485.70 | $1,675.56 | $1,873.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,487.58 / $1,487.58 / $1,886.50
| Professional | | $1,487.58 | $1,487.58 | $1,886.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,503.13 / $1,503.13 / $1,503.13
| Professional | | $1,503.13 | $1,503.13 | $1,503.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,939.66 / $1,939.66 / $1,939.66
| Professional | | $1,939.66 | $1,939.66 | $1,939.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,025.99 / $1,296.04 / $1,757.93
| Professional | | $1,025.99 | $1,296.04 | $1,757.93 |