- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,454.94 / $1,454.94 / $1,745.93
| Facility | | $1,454.94 | $1,454.94 | $1,745.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,454.94 / $1,512.06 / $2,246.08
| Professional | | $1,454.94 | $1,512.06 | $2,246.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,339.10 / $2,339.10 / $2,339.10
| Professional | | $2,339.10 | $2,339.10 | $2,339.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.76 / $2,837.98 / $2,837.98
| Professional | | $287.76 | $2,837.98 | $2,837.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,141.22 / $1,785.43 / $2,633.84
| Professional | | $1,141.22 | $1,785.43 | $2,633.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,310.80 / $2,560.32 / $3,258.58
| Professional | | $2,310.80 | $2,560.32 | $3,258.58 |