- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,221.22 / $3,221.22 / $3,221.22
| Facility | | $3,221.22 | $3,221.22 | $3,221.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,636.02 / $3,221.22 / $3,221.22
| Professional | | $1,636.02 | $3,221.22 | $3,221.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,381.07 / $2,381.07 / $3,811.37
| Facility | | $2,381.07 | $2,381.07 | $3,811.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,738.18 / $2,381.07 / $3,337.37
| Professional | | $1,738.18 | $2,381.07 | $3,337.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,132.68 / $1,911.75 / $2,631.84
| Professional | | $1,132.68 | $1,911.75 | $2,631.84 |