- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,665.34 / $1,665.34 / $1,665.34
| Facility | | $1,665.34 | $1,665.34 | $1,665.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.74 / $1,389.03 / $1,692.17
| Professional | | $1,348.74 | $1,389.03 | $1,692.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.08 / $1,342.67 / $1,949.56
| Professional | | $60.08 | $1,342.67 | $1,949.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,996.77 / $1,996.77 / $2,194.46
| Professional | | $1,996.77 | $1,996.77 | $2,194.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,342.67 / $1,342.67 / $1,342.67
| Professional | | $1,342.67 | $1,342.67 | $1,342.67 |