- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,333.46 / $2,333.46 / $2,333.46
| Facility | | $2,333.46 | $2,333.46 | $2,333.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,511.60 / $2,717.01 / $3,484.42
| Professional | | $1,511.60 | $2,717.01 | $3,484.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,837.13 / $3,660.81 / $4,188.33
| Facility | | $2,837.13 | $3,660.81 | $4,188.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,868.89 / $1,868.90 / $1,868.90
| Professional | | $1,868.89 | $1,868.90 | $1,868.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,420.25 / $2,402.01 / $4,739.43
| Professional | | $1,420.25 | $2,402.01 | $4,739.43 |