- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,786.69 / $2,786.69 / $2,786.69
| Facility | | $2,786.69 | $2,786.69 | $2,786.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,415.32 / $2,786.69 / $2,786.69
| Professional | | $1,415.32 | $2,786.69 | $2,786.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,467.38 / $2,467.38 / $2,467.38
| Professional | | $2,467.38 | $2,467.38 | $2,467.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,637.76 / $2,637.76 / $4,077.61
| Facility | | $2,637.76 | $2,637.76 | $4,077.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.56 / $2,637.76 / $3,570.50
| Professional | | $1,925.56 | $2,637.76 | $3,570.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,102.57 / $1,653.86 / $2,665.69
| Professional | | $1,102.57 | $1,653.86 | $2,665.69 |