- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,141.53 / $4,141.53 / $4,141.53
| Facility | | $4,141.53 | $4,141.53 | $4,141.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,103.42 / $4,141.53 / $4,141.53
| Professional | | $2,103.42 | $4,141.53 | $4,141.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,666.98 / $3,666.98 / $3,666.98
| Professional | | $3,666.98 | $3,666.98 | $3,666.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,802.84 / $2,802.84 / $5,025.57
| Facility | | $2,802.84 | $2,802.84 | $5,025.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,382.41 / $2,802.84 / $4,689.42
| Professional | | $2,382.41 | $2,802.84 | $4,689.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,491.86 / $2,457.94 / $3,448.38
| Professional | | $1,491.86 | $2,457.94 | $3,448.38 |