- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,248.07 / $5,248.07
| Facility | | $4,265.80 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,466.84 / $7,244.36
| Professional | | $4,265.80 | $4,466.84 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $2,398.83
| Professional | | $1,905.46 | $1,905.46 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $6,760.83 / $12,882.50
| Facility | | $2,884.03 | $6,760.83 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $5,248.07 / $5,248.07
| Professional | | $1,995.26 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Professional | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $5,754.40
| Professional | | $5,248.07 | $5,248.07 | $5,754.40 |