- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,737.97 / $3,737.97 / $3,737.97
| Facility | | $3,737.97 | $3,737.97 | $3,737.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,898.47 / $3,737.97 / $3,737.97
| Professional | | $1,898.47 | $3,737.97 | $3,737.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,582.02 / $3,582.02 / $3,582.02
| Professional | | $3,582.02 | $3,582.02 | $3,582.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,060.59 / $3,060.59 / $4,422.75
| Facility | | $3,060.59 | $3,060.59 | $4,422.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,234.23 / $2,234.23 / $5,127.38
| Professional | | $2,234.23 | $2,234.23 | $5,127.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.07 / $2,218.42 / $3,177.03
| Professional | | $1,314.07 | $2,218.42 | $3,177.03 |