- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,378.42 / $4,378.42 / $4,378.42
| Facility | | $4,378.42 | $4,378.42 | $4,378.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,220.17 / $4,378.42 / $4,483.93
| Professional | | $4,220.17 | $4,378.42 | $4,483.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,483.93 / $4,483.93 / $4,483.93
| Facility | | $4,483.93 | $4,483.93 | $4,483.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,483.93 / $4,483.93 / $4,483.93
| Professional | | $4,483.93 | $4,483.93 | $4,483.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,483.93 / $7,450.04 / $7,450.04
| Facility | | $4,483.93 | $7,450.04 | $7,450.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,220.54 / $10,220.54 / $11,487.38
| Professional | | $10,220.54 | $10,220.54 | $11,487.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.45 / $5,275.21 / $5,275.21
| Professional | | $5,011.45 | $5,275.21 | $5,275.21 |