- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,476.20 / $1,476.20 / $1,476.20
| Facility | | $1,476.20 | $1,476.20 | $1,476.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,332.43 / $1,398.77 / $1,692.17
| Professional | | $1,332.43 | $1,398.77 | $1,692.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,996.77 / $2,095.62 / $2,510.79
| Professional | | $1,996.77 | $2,095.62 | $2,510.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.17 / $1,723.48 / $2,292.23
| Professional | | $1,130.17 | $1,723.48 | $2,292.23 |
- 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 |