- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,127.70 / $3,127.70 / $3,127.70
| Facility | | $3,127.70 | $3,127.70 | $3,127.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,588.51 / $3,127.70 / $3,127.70
| Professional | | $1,588.51 | $3,127.70 | $3,127.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,769.32 / $2,769.32 / $2,769.32
| Professional | | $2,769.32 | $2,769.32 | $2,769.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,717.61 / $2,717.61 / $4,293.29
| Facility | | $2,717.61 | $2,717.61 | $4,293.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,983.86 / $2,717.61 / $3,759.36
| Professional | | $1,983.86 | $2,717.61 | $3,759.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.74 / $1,856.24 / $2,844.80
| Professional | | $1,230.74 | $1,856.24 | $2,844.80 |