- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,357.54 / $3,357.54 / $3,357.54
| Facility | | $3,357.54 | $3,357.54 | $3,357.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,956.13 / $2,423.27 / $2,423.27
| Professional | | $1,956.13 | $2,423.27 | $2,423.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,897.74 / $1,897.74 / $1,897.74
| Facility | | $1,897.74 | $1,897.74 | $1,897.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,354.80 / $3,354.80 / $4,193.50
| Professional | | $3,354.80 | $3,354.80 | $4,193.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,751.76 / $6,423.12
| Professional | | $1,226.23 | $1,751.76 | $6,423.12 |