- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $1,494.41
| Facility | | $1,494.41 | $1,494.41 | $1,494.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $1,494.41
| Professional | | $1,494.41 | $1,494.41 | $1,494.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.86 / $1,445.86 / $1,445.86
| Professional | | $1,445.86 | $1,445.86 | $1,445.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,409.82 / $1,409.82 / $1,494.41
| Facility | | $1,409.82 | $1,409.82 | $1,494.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $1,903.26
| Professional | | $1,494.41 | $1,494.41 | $1,903.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,270.25 / $1,270.25 / $2,547.46
| Professional | | $1,270.25 | $1,270.25 | $2,547.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $2,422.11
| Professional | | $1,494.41 | $1,494.41 | $2,422.11 |