- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.26 / $1,949.26 / $1,949.26
| Facility | | $1,949.26 | $1,949.26 | $1,949.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,541.52 / $1,949.26 / $2,436.58
| Professional | | $1,541.52 | $1,949.26 | $2,436.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,961.58 / $4,961.58 / $4,961.58
| Professional | | $4,961.58 | $4,961.58 | $4,961.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,342.55 / $2,342.55 / $2,342.55
| Facility | | $2,342.55 | $2,342.55 | $2,342.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,807.53 / $3,020.09 / $3,092.00
| Professional | | $1,807.53 | $3,020.09 | $3,092.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,721.45 / $2,869.08 / $2,869.08
| Professional | | $1,721.45 | $2,869.08 | $2,869.08 |