- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,707.67 / $3,707.67 / $3,707.67
| Facility | | $3,707.67 | $3,707.67 | $3,707.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,883.08 / $3,707.67 / $3,707.67
| Professional | | $1,883.08 | $3,707.67 | $3,707.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,749.10 / $3,749.10 / $4,343.71
| Professional | | $3,749.10 | $3,749.10 | $4,343.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,922.36 / $2,922.36 / $2,922.36
| Professional | | $2,922.36 | $2,922.36 | $2,922.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,448.80 / $2,448.80 / $4,386.88
| Facility | | $2,448.80 | $2,448.80 | $4,386.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,787.62 / $2,448.80 / $3,841.31
| Professional | | $1,787.62 | $2,448.80 | $3,841.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,303.42 / $2,200.44 / $3,121.83
| Professional | | $1,303.42 | $2,200.44 | $3,121.83 |