- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,067.11 / $1,067.11 / $1,067.11
| Facility | | $1,067.11 | $1,067.11 | $1,067.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.55 / $1,067.11 / $1,285.69
| Professional | | $1,028.55 | $1,067.11 | $1,285.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,092.83 / $1,092.83 / $1,092.83
| Professional | | $1,092.83 | $1,092.83 | $1,092.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $1,135.69 / $1,453.68
| Professional | | $60.00 | $1,135.69 | $1,453.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.96 / $624.04 / $2,164.17
| Facility | | $562.96 | $624.04 | $2,164.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.41 / $1,071.41 / $1,071.41
| Professional | | $1,071.41 | $1,071.41 | $1,071.41 |