- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,307.30 / $1,307.30 / $2,042.65
| Facility | | $1,307.30 | $1,307.30 | $2,042.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,307.30 / $2,042.65 / $2,503.90
| Professional | | $1,307.30 | $2,042.65 | $2,503.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,807.72 / $1,807.72 / $1,807.72
| Facility | | $1,807.72 | $1,807.72 | $1,807.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,807.72 / $1,807.72 / $1,807.72
| Professional | | $1,807.72 | $1,807.72 | $1,807.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,823.10 / $1,823.10 / $1,823.10
| Facility | | $1,823.10 | $1,823.10 | $1,823.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,330.86 / $1,330.86 / $1,823.10
| Professional | | $1,330.86 | $1,330.86 | $1,823.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $775.86 / $1,163.79 / $1,793.37
| Professional | | $775.86 | $1,163.79 | $1,793.37 |