- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,542.24 / $1,542.24 / $1,542.24
| Facility | | $1,542.24 | $1,542.24 | $1,542.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,628.91 / $1,643.85
| Professional | | $1,494.41 | $1,628.91 | $1,643.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,406.17 / $2,830.80 / $2,830.80
| Professional | | $2,406.17 | $2,830.80 | $2,830.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,409.82 / $1,409.82 / $1,409.82
| Facility | | $1,409.82 | $1,409.82 | $1,409.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $2,114.73 / $2,114.73
| Professional | | $1,494.41 | $2,114.73 | $2,114.73 |
- 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 |