- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,425.41 / $2,425.41 / $2,425.41
| Facility | | $2,425.41 | $2,425.41 | $2,425.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,231.83 / $2,425.41 / $2,425.41
| Professional | | $1,231.83 | $2,425.41 | $2,425.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,147.50 / $2,147.50 / $2,147.50
| Professional | | $2,147.50 | $2,147.50 | $2,147.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,289.62 / $2,289.62 / $3,539.42
| Facility | | $2,289.62 | $2,289.62 | $3,539.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,671.42 / $1,671.42 / $4,103.25
| Professional | | $1,671.42 | $1,671.42 | $4,103.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $959.63 / $1,439.45 / $2,320.10
| Professional | | $959.63 | $1,439.45 | $2,320.10 |