- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,972.64 / $3,972.64 / $3,972.64
| Facility | | $3,972.64 | $3,972.64 | $3,972.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,017.65 / $3,972.64 / $3,972.64
| Professional | | $2,017.65 | $3,972.64 | $3,972.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,517.44 / $3,517.44 / $3,517.44
| Professional | | $3,517.44 | $3,517.44 | $3,517.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,001.57 / $3,001.57 / $5,095.91
| Facility | | $3,001.57 | $3,001.57 | $5,095.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,191.15 / $3,001.57 / $4,462.14
| Professional | | $2,191.15 | $3,001.57 | $4,462.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,316.73 / $2,357.69 / $3,226.17
| Professional | | $1,316.73 | $2,357.69 | $3,226.17 |