- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,471.81 / $3,471.81 / $3,471.81
| Facility | | $3,471.81 | $3,471.81 | $3,471.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,763.29 / $3,471.81 / $3,471.81
| Professional | | $1,763.29 | $3,471.81 | $3,471.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,074.00 / $3,074.00 / $3,074.00
| Professional | | $3,074.00 | $3,074.00 | $3,074.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,148.57 / $3,148.57 / $4,409.35
| Facility | | $3,148.57 | $3,148.57 | $4,409.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,298.46 / $3,148.57 / $3,931.10
| Professional | | $2,298.46 | $3,148.57 | $3,931.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,373.64 / $2,060.46 / $3,175.12
| Professional | | $1,373.64 | $2,060.46 | $3,175.12 |