- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,541.53 / $2,541.53 / $2,541.53
| Facility | | $2,541.53 | $2,541.53 | $2,541.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,290.81 / $2,541.53 / $2,541.53
| Professional | | $1,290.81 | $2,541.53 | $2,541.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,003.20 / $2,003.20 / $2,003.20
| Professional | | $2,003.20 | $2,003.20 | $2,003.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,902.78 / $1,902.78 / $2,941.43
| Facility | | $1,902.78 | $1,902.78 | $2,941.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,389.03 / $1,902.78 / $2,575.62
| Professional | | $1,389.03 | $1,902.78 | $2,575.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $978.30 / $1,508.36 / $2,261.29
| Professional | | $978.30 | $1,508.36 | $2,261.29 |