- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,690.48 / $3,690.48 / $3,690.48
| Facility | | $3,690.48 | $3,690.48 | $3,690.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,874.35 / $3,690.48 / $3,690.48
| Professional | | $1,874.35 | $3,690.48 | $3,690.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,267.61 / $3,267.61 / $3,267.61
| Professional | | $3,267.61 | $3,267.61 | $3,267.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,728.17 / $2,728.17 / $4,388.25
| Facility | | $2,728.17 | $2,728.17 | $4,388.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,991.56 / $1,991.56 / $5,087.25
| Professional | | $1,991.56 | $1,991.56 | $5,087.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.72 / $2,190.25 / $3,048.16
| Professional | | $1,318.72 | $2,190.25 | $3,048.16 |