- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,849.16 / $2,849.16 / $2,849.16
| Facility | | $2,849.16 | $2,849.16 | $2,849.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,447.05 / $2,849.16 / $2,849.16
| Professional | | $1,447.05 | $2,849.16 | $2,849.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,542.06 / $2,542.06 / $2,542.06
| Professional | | $2,542.06 | $2,542.06 | $2,542.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,440.82 / $2,440.82 / $2,440.82
| Professional | | $2,440.82 | $2,440.82 | $2,440.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,117.90 / $2,117.90 / $3,557.34
| Facility | | $2,117.90 | $2,117.90 | $3,557.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,546.07 / $1,546.07 / $4,123.88
| Professional | | $1,546.07 | $1,546.07 | $4,123.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.29 / $1,690.94 / $2,605.67
| Professional | | $1,127.29 | $1,690.94 | $2,605.67 |