- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,797.03 / $2,797.03 / $2,797.03
| Facility | | $2,797.03 | $2,797.03 | $2,797.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,420.57 / $2,797.03 / $2,797.03
| Professional | | $1,420.57 | $2,797.03 | $2,797.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,476.53 / $2,476.53 / $2,476.53
| Professional | | $2,476.53 | $2,476.53 | $2,476.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,425.11 / $2,425.11 / $3,748.87
| Facility | | $2,425.11 | $2,425.11 | $3,748.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.33 / $2,425.11 / $3,282.65
| Professional | | $1,770.33 | $2,425.11 | $3,282.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.24 / $1,660.00 / $2,427.57
| Professional | | $1,050.24 | $1,660.00 | $2,427.57 |