- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,400.76 / $2,400.76 / $2,400.76
| Facility | | $2,400.76 | $2,400.76 | $2,400.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,219.31 / $2,400.76 / $2,400.76
| Professional | | $1,219.31 | $2,400.76 | $2,400.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,125.67 / $2,125.67 / $2,125.67
| Professional | | $2,125.67 | $2,125.67 | $2,125.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,050.41 / $2,050.41 / $2,909.74
| Facility | | $2,050.41 | $2,050.41 | $2,909.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.80 / $1,496.80 / $3,373.13
| Professional | | $1,496.80 | $1,496.80 | $3,373.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.88 / $1,424.81 / $2,195.59
| Professional | | $949.88 | $1,424.81 | $2,195.59 |