- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,740.83 / $3,740.83 / $3,740.83
| Facility | | $3,740.83 | $3,740.83 | $3,740.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,899.92 / $3,740.83 / $3,740.83
| Professional | | $1,899.92 | $3,740.83 | $3,740.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,651.44 / $2,651.44 / $2,651.44
| Professional | | $2,651.44 | $2,651.44 | $2,651.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,780.72 / $2,780.72 / $4,585.87
| Facility | | $2,780.72 | $2,780.72 | $4,585.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,029.93 / $2,780.72 / $4,015.55
| Professional | | $2,029.93 | $2,780.72 | $4,015.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,480.08 / $2,220.13 / $3,421.15
| Professional | | $1,480.08 | $2,220.13 | $3,421.15 |