- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,564.86 / $2,564.86 / $2,564.86
| Facility | | $2,564.86 | $2,564.86 | $2,564.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,302.66 / $2,564.86 / $2,564.86
| Professional | | $1,302.66 | $2,564.86 | $2,564.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,270.96 / $2,270.96 / $2,270.96
| Professional | | $2,270.96 | $2,270.96 | $2,270.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,665.63 / $1,665.63 / $2,574.83
| Facility | | $1,665.63 | $1,665.63 | $2,574.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,215.91 / $1,665.63 / $2,261.67
| Professional | | $1,215.91 | $1,665.63 | $2,261.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $761.10 / $1,522.21 / $1,840.12
| Professional | | $761.10 | $1,522.21 | $1,840.12 |