- 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
- $2,988.99 / $3,205.54 / $3,205.54
| Professional | | $2,988.99 | $3,205.54 | $3,205.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,334.96 / $3,334.96 / $6,687.55
| Facility | | $3,334.96 | $3,334.96 | $6,687.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,269.36 / $3,205.54 / $3,846.65
| Facility | | $2,269.36 | $3,205.54 | $3,846.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,751.11 / $2,751.11 / $2,751.11
| Professional | | $2,751.11 | $2,751.11 | $2,751.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,826.34 / $3,043.90 / $9,232.77
| Professional | | $1,826.34 | $3,043.90 | $9,232.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,381.23 / $17,388.84 / $17,388.84
| Facility | | $3,381.23 | $17,388.84 | $17,388.84 |