- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,205.54 / $3,205.54 / $3,205.54
| Facility | | $3,205.54 | $3,205.54 | $3,205.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,923.32 / $3,205.54 / $3,205.54
| Professional | | $1,923.32 | $3,205.54 | $3,205.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,978.67 / $2,978.67 / $3,276.54
| Facility | | $2,978.67 | $2,978.67 | $3,276.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,484.42 / $3,484.42 / $3,484.42
| Professional | | $3,484.42 | $3,484.42 | $3,484.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $1,275.00
| Professional | | $1,275.00 | $1,275.00 | $1,275.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,217.56 / $3,043.90 / $4,089.93
| Professional | | $1,217.56 | $3,043.90 | $4,089.93 |