- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,207.77 / $4,207.77 / $4,207.77
| Facility | | $4,207.77 | $4,207.77 | $4,207.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,518.75 / $4,710.35 / $5,259.71
| Professional | | $3,518.75 | $4,710.35 | $5,259.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,686.15 / $2,686.15 / $3,943.39
| Professional | | $2,686.15 | $2,686.15 | $3,943.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,506.48 / $3,506.48 / $4,207.77
| Facility | | $3,506.48 | $3,506.48 | $4,207.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,192.20 / $2,805.18 / $4,675.30
| Professional | | $1,192.20 | $2,805.18 | $4,675.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.81 / $2,384.40 / $3,974.01
| Professional | | $981.81 | $2,384.40 | $3,974.01 |