- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,220.17 / $4,220.17 / $4,220.17
| Facility | | $4,220.17 | $4,220.17 | $4,220.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,220.17 / $4,378.42 / $5,275.21
| Professional | | $4,220.17 | $4,378.42 | $5,275.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,903.13 / $2,378.91 / $4,483.93
| Professional | | $1,903.13 | $2,378.91 | $4,483.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,252.85 / $4,483.93 / $7,174.29
| Facility | | $1,252.85 | $4,483.93 | $7,174.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,275.21 / $5,275.21 / $10,220.54
| Professional | | $5,275.21 | $5,275.21 | $10,220.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,275.21 / $5,275.21 / $5,802.73
| Professional | | $5,275.21 | $5,275.21 | $5,802.73 |