- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,376.79 / $1,376.79 / $1,376.79
| Facility | | $1,376.79 | $1,376.79 | $1,376.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.35 / $1,336.58 / $1,455.68
| Professional | | $1,323.35 | $1,336.58 | $1,455.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,434.12 / $1,687.20 / $1,687.20
| Professional | | $1,434.12 | $1,687.20 | $1,687.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,248.44 / $1,248.44 / $1,248.44
| Facility | | $1,248.44 | $1,248.44 | $1,248.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.35 / $1,622.97 / $1,872.66
| Professional | | $1,323.35 | $1,622.97 | $1,872.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.35 / $1,323.35 / $1,323.35
| Professional | | $1,323.35 | $1,323.35 | $1,323.35 |