- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.36 / $2,818.36 / $2,818.36
| Facility | | $2,818.36 | $2,818.36 | $2,818.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $961.45 / $2,818.36 / $3,166.32
| Professional | | $961.45 | $2,818.36 | $3,166.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,466.29 / $3,941.86 / $5,250.56
| Professional | | $2,466.29 | $3,941.86 | $5,250.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.36 / $6,291.99 / $8,644.37
| Facility | | $2,818.36 | $6,291.99 | $8,644.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,283.94 / $3,513.76 / $8,015.47
| Professional | | $2,283.94 | $3,513.76 | $8,015.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,986.70 / $5,138.93 / $7,183.86
| Professional | | $2,986.70 | $5,138.93 | $7,183.86 |