- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,206.67 / $2,206.67 / $2,206.67
| Facility | | $2,206.67 | $2,206.67 | $2,206.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,044.57 / $2,206.67 / $2,206.67
| Professional | | $1,044.57 | $2,206.67 | $2,206.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,821.04 / $1,821.04 / $1,821.04
| Professional | | $1,821.04 | $1,821.04 | $1,821.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,638.80 / $1,638.80 / $2,533.35
| Facility | | $1,638.80 | $1,638.80 | $2,533.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,196.32 / $1,196.32 / $2,937.00
| Professional | | $1,196.32 | $1,196.32 | $2,937.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,203.23 / $1,203.23 / $1,416.40
| Facility | | $1,203.23 | $1,203.23 | $1,416.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $809.37 / $1,214.06 / $1,828.81
| Professional | | $809.37 | $1,214.06 | $1,828.81 |