- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,281.19 / $2,281.19 / $2,281.19
| Facility | | $2,281.19 | $2,281.19 | $2,281.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,158.58 / $2,281.19 / $2,281.19
| Professional | | $1,158.58 | $2,281.19 | $2,281.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,482.94 / $1,482.94 / $2,655.63
| Facility | | $1,482.94 | $1,482.94 | $2,655.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.50 / $1,482.94 / $2,582.98
| Professional | | $1,260.50 | $1,482.94 | $2,582.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $789.32 / $1,353.86 / $1,863.81
| Professional | | $789.32 | $1,353.86 | $1,863.81 |