- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,394.73 / $2,394.73 / $2,394.73
| Facility | | $2,394.73 | $2,394.73 | $2,394.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,216.25 / $2,394.73 / $2,394.73
| Professional | | $1,216.25 | $2,394.73 | $2,394.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,120.34 / $2,120.34 / $2,120.34
| Professional | | $2,120.34 | $2,120.34 | $2,120.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,960.76 / $1,960.76 / $3,031.05
| Facility | | $1,960.76 | $1,960.76 | $3,031.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,431.35 / $1,960.76 / $2,654.09
| Professional | | $1,431.35 | $1,960.76 | $2,654.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.07 / $1,421.24 / $1,956.97
| Professional | | $817.07 | $1,421.24 | $1,956.97 |