- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,780.57 / $2,780.57 / $2,780.57
| Facility | | $2,780.57 | $2,780.57 | $2,780.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,345.11 / $2,780.57 / $3,147.79
| Professional | | $2,345.11 | $2,780.57 | $3,147.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $517.04 / $517.04 / $532.85
| Facility | | $517.04 | $517.04 | $532.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $532.85 / $532.85 / $532.85
| Professional | | $532.85 | $532.85 | $532.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.35 / $248.35 / $396.83
| Professional | | $248.35 | $248.35 | $396.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $264.94 / $2,877.04
| Professional | | $151.16 | $264.94 | $2,877.04 |