- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,551.48 / $2,551.48 / $2,551.48
| Facility | | $2,551.48 | $2,551.48 | $2,551.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,295.85 / $2,551.48 / $2,551.48
| Professional | | $1,295.85 | $2,551.48 | $2,551.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,259.12 / $2,259.12 / $2,259.12
| Professional | | $2,259.12 | $2,259.12 | $2,259.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,952.91 / $1,952.91 / $3,018.93
| Facility | | $1,952.91 | $1,952.91 | $3,018.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,425.62 / $1,952.91 / $2,643.48
| Professional | | $1,425.62 | $1,952.91 | $2,643.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $896.96 / $1,514.26 / $2,128.07
| Professional | | $896.96 | $1,514.26 | $2,128.07 |