- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,838.16 / $3,838.16 / $3,838.16
| Facility | | $3,838.16 | $3,838.16 | $3,838.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.35 / $3,838.16 / $3,838.16
| Professional | | $1,949.35 | $3,838.16 | $3,838.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,398.37 / $3,398.37 / $3,398.37
| Professional | | $3,398.37 | $3,398.37 | $3,398.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,853.06 / $2,853.06 / $5,756.63
| Facility | | $2,853.06 | $2,853.06 | $5,756.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,082.73 / $2,853.06 / $5,040.71
| Professional | | $2,082.73 | $2,853.06 | $5,040.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.59 / $2,277.89 / $3,510.16
| Professional | | $1,518.59 | $2,277.89 | $3,510.16 |