- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.10 / $1,737.10 / $1,737.10
| Facility | | $1,737.10 | $1,737.10 | $1,737.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.32 / $1,730.32 / $1,737.10
| Professional | | $1,730.32 | $1,730.32 | $1,737.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,837.13 / $2,161.33 / $2,161.33
| Professional | | $1,837.13 | $2,161.33 | $2,161.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,632.38 / $1,632.38 / $1,632.38
| Facility | | $1,632.38 | $1,632.38 | $1,632.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.32 / $1,730.32 / $2,448.57
| Professional | | $1,730.32 | $1,730.32 | $2,448.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.32 / $1,730.32 / $1,926.21
| Professional | | $1,730.32 | $1,730.32 | $1,926.21 |