- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,370.73 / $1,370.73 / $1,370.73
| Facility | | $1,370.73 | $1,370.73 | $1,370.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,555.92 / $1,570.20
| Professional | | $1,427.45 | $1,555.92 | $1,570.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.00 / $1,740.00 / $1,740.00
| Professional | | $1,479.00 | $1,740.00 | $1,740.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,346.65 / $1,346.65 / $1,346.65
| Facility | | $1,346.65 | $1,346.65 | $1,346.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $2,019.98 / $2,019.98
| Professional | | $1,427.45 | $2,019.98 | $2,019.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,427.45 / $1,427.45
| Professional | | $1,427.45 | $1,427.45 | $1,427.45 |