- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,211.30 / $2,211.30 / $3,053.70
| Facility | | $2,211.30 | $2,211.30 | $3,053.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.00 / $1,702.35 / $2,211.30
| Professional | | $1,053.00 | $1,702.35 | $2,211.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,140.75 / $1,323.27 / $2,292.91
| Facility | | $1,140.75 | $1,323.27 | $2,292.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,579.50 / $1,579.50 / $1,579.50
| Facility | | $1,579.50 | $1,579.50 | $1,579.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.10 / $1,053.00 / $1,755.00
| Professional | | $737.10 | $1,053.00 | $1,755.00 |