- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,542.34 / $3,542.34 / $3,542.34
| Facility | | $3,542.34 | $3,542.34 | $3,542.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,799.11 / $3,542.34 / $3,542.34
| Professional | | $1,799.11 | $3,542.34 | $3,542.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,136.45 / $3,136.45 / $3,136.45
| Professional | | $3,136.45 | $3,136.45 | $3,136.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,741.63 / $2,741.63 / $4,511.30
| Facility | | $2,741.63 | $2,741.63 | $4,511.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.39 / $2,741.63 / $4,010.97
| Professional | | $2,001.39 | $2,741.63 | $4,010.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,401.55 / $2,102.33 / $3,239.62
| Professional | | $1,401.55 | $2,102.33 | $3,239.62 |