- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,434.20 / $3,434.20 / $3,434.20
| Facility | | $3,434.20 | $3,434.20 | $3,434.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,744.19 / $3,434.20 / $3,434.20
| Professional | | $1,744.19 | $3,434.20 | $3,434.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,706.81 / $2,706.81 / $2,706.81
| Professional | | $2,706.81 | $2,706.81 | $2,706.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,282.71 / $2,282.71 / $4,063.39
| Facility | | $2,282.71 | $2,282.71 | $4,063.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,666.39 / $1,666.39 / $4,710.75
| Professional | | $1,666.39 | $1,666.39 | $4,710.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,982.23 / $1,982.23 / $1,982.23
| Facility | | $1,982.23 | $1,982.23 | $1,982.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,215.02 / $2,038.15 / $2,882.66
| Professional | | $1,215.02 | $2,038.15 | $2,882.66 |