- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,589.09 / $3,589.09 / $3,589.09
| Facility | | $3,589.09 | $3,589.09 | $3,589.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,838.34 / $3,589.09 / $4,486.37
| Professional | | $2,838.34 | $3,589.09 | $4,486.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,385.44 / $8,385.44 / $8,385.44
| Professional | | $8,385.44 | $8,385.44 | $8,385.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,556.68 / $3,556.68 / $3,556.68
| Facility | | $3,556.68 | $3,556.68 | $3,556.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,744.35 / $3,092.00 / $3,556.68
| Professional | | $2,744.35 | $3,092.00 | $3,556.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,613.65 / $4,356.08 / $4,356.08
| Professional | | $2,613.65 | $4,356.08 | $4,356.08 |