- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,016.70 / $2,016.70 / $2,016.70
| Facility | | $2,016.70 | $2,016.70 | $2,016.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,807.25 / $1,948.22 / $2,028.50
| Professional | | $1,807.25 | $1,948.22 | $2,028.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.42 / $479.31 / $571.46
| Facility | | $407.42 | $479.31 | $571.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,349.75 / $2,373.25 / $2,984.18
| Professional | | $2,349.75 | $2,373.25 | $2,984.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,807.25 / $2,016.70 / $3,531.59
| Facility | | $1,807.25 | $2,016.70 | $3,531.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.73 / $68.73 / $84.10
| Professional | | $68.73 | $68.73 | $84.10 |