- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,380.03 / $2,380.03 / $2,380.03
| Facility | | $2,380.03 | $2,380.03 | $2,380.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,208.79 / $2,380.03 / $2,380.03
| Professional | | $1,208.79 | $2,380.03 | $2,380.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,107.32 / $2,107.32 / $2,107.32
| Professional | | $2,107.32 | $2,107.32 | $2,107.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,769.18 / $1,769.18 / $3,394.81
| Facility | | $1,769.18 | $1,769.18 | $3,394.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.50 / $1,769.18 / $2,972.61
| Professional | | $1,291.50 | $1,769.18 | $2,972.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $941.68 / $1,412.51 / $2,176.64
| Professional | | $941.68 | $1,412.51 | $2,176.64 |