- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,245.66 / $3,245.66 / $3,245.66
| Facility | | $3,245.66 | $3,245.66 | $3,245.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,648.43 / $3,245.66 / $3,245.66
| Professional | | $1,648.43 | $3,245.66 | $3,245.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,873.77 / $2,873.77 / $2,873.77
| Professional | | $2,873.77 | $2,873.77 | $2,873.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,141.52 / $3,141.52 / $4,856.35
| Facility | | $3,141.52 | $3,141.52 | $4,856.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,293.31 / $3,141.52 / $4,252.39
| Professional | | $2,293.31 | $3,141.52 | $4,252.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,211.39 / $1,926.25 / $2,800.07
| Professional | | $1,211.39 | $1,926.25 | $2,800.07 |