- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,484.42 / $3,484.42 / $3,484.42
| Facility | | $3,484.42 | $3,484.42 | $3,484.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,233.09 / $3,205.54 / $3,484.42
| Professional | | $2,233.09 | $3,205.54 | $3,484.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,908.18 / $3,660.81 / $4,576.01
| Professional | | $2,908.18 | $3,660.81 | $4,576.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,650.67 / $3,484.42 / $4,703.97
| Facility | | $1,650.67 | $3,484.42 | $4,703.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,454.09 / $1,454.09 / $1,454.09
| Professional | | $1,454.09 | $1,454.09 | $1,454.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,217.56 / $2,836.83 / $3,469.26
| Professional | | $1,217.56 | $2,836.83 | $3,469.26 |