- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,496.92 / $3,496.92 / $3,496.92
| Facility | | $3,496.92 | $3,496.92 | $3,496.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,655.33 / $3,496.92 / $3,496.92
| Professional | | $1,655.33 | $3,496.92 | $3,496.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,885.81 / $2,885.81 / $2,885.81
| Professional | | $2,885.81 | $2,885.81 | $2,885.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,326.75 / $2,326.75 / $3,856.33
| Facility | | $2,326.75 | $2,326.75 | $3,856.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.53 / $2,326.75 / $3,376.74
| Professional | | $1,698.53 | $2,326.75 | $3,376.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,145.77 / $1,718.66 / $2,718.36
| Professional | | $1,145.77 | $1,718.66 | $2,718.36 |