- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,471.63 / $3,471.63 / $3,471.63
| Facility | | $3,471.63 | $3,471.63 | $3,471.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,763.19 / $3,471.63 / $3,471.63
| Professional | | $1,763.19 | $3,471.63 | $3,471.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,604.32 / $2,604.32 / $2,604.32
| Professional | | $2,604.32 | $2,604.32 | $2,604.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,550.04 / $2,550.04 / $4,593.82
| Facility | | $2,550.04 | $2,550.04 | $4,593.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,861.53 / $2,550.04 / $4,022.51
| Professional | | $1,861.53 | $2,550.04 | $4,022.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,625.10 / $4,625.10 / $5,441.30
| Facility | | $4,625.10 | $4,625.10 | $5,441.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,357.30 / $2,060.36 / $3,137.34
| Professional | | $1,357.30 | $2,060.36 | $3,137.34 |