- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,727.80 / $2,727.80 / $2,727.80
| Facility | | $2,727.80 | $2,727.80 | $2,727.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.26 / $2,727.80 / $2,727.80
| Professional | | $1,291.26 | $2,727.80 | $2,727.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,251.10 / $2,251.10 / $2,251.10
| Professional | | $2,251.10 | $2,251.10 | $2,251.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,815.81 / $1,815.81 / $3,220.50
| Facility | | $1,815.81 | $1,815.81 | $3,220.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,325.54 / $1,815.81 / $2,819.98
| Professional | | $1,325.54 | $1,815.81 | $2,819.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $966.50 / $1,449.74 / $2,183.83
| Professional | | $966.50 | $1,449.74 | $2,183.83 |