- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,042.67 / $2,042.67 / $2,042.67
| Facility | | $2,042.67 | $2,042.67 | $2,042.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,049.24 / $1,061.98 / $1,235.45
| Professional | | $1,049.24 | $1,061.98 | $1,235.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,238.93 / $1,457.56 / $1,457.56
| Professional | | $1,238.93 | $1,457.56 | $1,457.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,238.93 / $1,238.93 / $1,238.93
| Professional | | $1,238.93 | $1,238.93 | $1,238.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.63 / $1,214.63 / $1,214.63
| Professional | | $1,214.63 | $1,214.63 | $1,214.63 |