- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,272.21 / $3,272.21 / $3,272.21
| Facility | | $3,272.21 | $3,272.21 | $3,272.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,661.92 / $3,272.21 / $3,272.21
| Professional | | $1,661.92 | $3,272.21 | $3,272.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,897.27 / $2,897.27 / $2,897.27
| Professional | | $2,897.27 | $2,897.27 | $2,897.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,970.85 / $2,970.85 / $4,215.93
| Facility | | $2,970.85 | $2,970.85 | $4,215.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,168.71 / $2,970.85 / $3,691.62
| Professional | | $2,168.71 | $2,970.85 | $3,691.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,231.75 / $1,942.01 / $2,950.18
| Professional | | $1,231.75 | $1,942.01 | $2,950.18 |