- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,075.80 / $3,798.72 / $4,213.88
| Facility | | $2,075.80 | $3,798.72 | $4,213.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,639.88 / $2,283.38 / $3,985.54
| Professional | | $1,639.88 | $2,283.38 | $3,985.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,075.80 / $2,075.80 / $2,075.80
| Facility | | $2,075.80 | $2,075.80 | $2,075.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,075.80 / $2,075.80 / $2,075.80
| Professional | | $2,075.80 | $2,075.80 | $2,075.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,385.08 / $2,385.08 / $2,981.34
| Professional | | $2,385.08 | $2,385.08 | $2,981.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.84 / $1,141.69 / $3,113.70
| Professional | | $871.84 | $1,141.69 | $3,113.70 |