- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,789.55 / $1,789.55 / $1,789.55
| Facility | | $1,789.55 | $1,789.55 | $1,789.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,969.89 / $2,147.17 / $2,166.88
| Professional | | $1,969.89 | $2,147.17 | $2,166.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,296.02 / $2,701.20 / $2,701.20
| Professional | | $2,296.02 | $2,701.20 | $2,701.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,858.38 / $1,858.38 / $1,858.38
| Facility | | $1,858.38 | $1,858.38 | $1,858.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,969.89 / $2,787.58 / $2,787.58
| Professional | | $1,969.89 | $2,787.58 | $2,787.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,969.89 / $1,969.89 / $1,969.89
| Professional | | $1,969.89 | $1,969.89 | $1,969.89 |