- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,347.66 / $2,347.66 / $3,242.00
| Facility | | $2,347.66 | $2,347.66 | $3,242.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.93 / $1,807.33 / $2,347.66
| Professional | | $1,117.93 | $1,807.33 | $2,347.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,211.08 / $1,404.86 / $2,434.29
| Facility | | $1,211.08 | $1,404.86 | $2,434.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,676.90 / $1,676.90 / $1,676.90
| Facility | | $1,676.90 | $1,676.90 | $1,676.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.55 / $1,117.93 / $1,863.22
| Professional | | $782.55 | $1,117.93 | $1,863.22 |