- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,589.36 / $2,589.36 / $2,589.36
| Facility | | $2,589.36 | $2,589.36 | $2,589.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,497.54 / $2,589.36 / $4,846.14
| Professional | | $1,497.54 | $2,589.36 | $4,846.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $872.05 / $1,235.00 / $2,171.50
| Professional | | $872.05 | $1,235.00 | $2,171.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.27 / $1,757.06 / $2,252.30
| Facility | | $1,096.27 | $1,757.06 | $2,252.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $834.14 / $1,069.39 / $1,646.21
| Professional | | $834.14 | $1,069.39 | $1,646.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $936.82 / $1,280.06 / $2,480.34
| Professional | | $936.82 | $1,280.06 | $2,480.34 |