- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,284.83 / $4,284.83 / $4,284.83
| Facility | | $4,284.83 | $4,284.83 | $4,284.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,176.21 / $4,284.83 / $4,284.83
| Professional | | $2,176.21 | $4,284.83 | $4,284.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,793.86 / $3,793.86 / $3,793.86
| Professional | | $3,793.86 | $3,793.86 | $3,793.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,578.08 / $3,578.08 / $5,531.20
| Facility | | $3,578.08 | $3,578.08 | $5,531.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,612.00 / $2,612.00 / $6,412.50
| Professional | | $2,612.00 | $2,612.00 | $6,412.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,607.34 / $2,542.96 / $3,715.30
| Professional | | $1,607.34 | $2,542.96 | $3,715.30 |