- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,844.36 / $2,844.36 / $2,844.36
| Facility | | $2,844.36 | $2,844.36 | $2,844.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,444.62 / $2,844.36 / $2,844.36
| Professional | | $1,444.62 | $2,844.36 | $2,844.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,518.44 / $2,518.44 / $2,518.44
| Professional | | $2,518.44 | $2,518.44 | $2,518.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,375.33 / $2,375.33 / $3,671.91
| Facility | | $2,375.33 | $2,375.33 | $3,671.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,733.99 / $2,375.33 / $3,215.25
| Professional | | $1,733.99 | $2,375.33 | $3,215.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,834.85 / $3,834.85 / $4,511.59
| Facility | | $3,834.85 | $3,834.85 | $4,511.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,125.39 / $1,688.09 / $2,601.29
| Professional | | $1,125.39 | $1,688.09 | $2,601.29 |