- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,672.73 / $3,672.73 / $3,672.73
| Facility | | $3,672.73 | $3,672.73 | $3,672.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,047.37 / $3,047.37 / $3,672.73
| Professional | | $3,047.37 | $3,047.37 | $3,672.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,997.08 / $5,847.72 / $5,948.80
| Professional | | $4,997.08 | $5,847.72 | $5,948.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,073.75 / $5,124.49 / $6,443.66
| Professional | | $5,073.75 | $5,124.49 | $6,443.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,333.54 / $3,672.73 / $5,250.47
| Facility | | $2,333.54 | $3,672.73 | $5,250.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,118.80 / $2,237.60 / $3,192.77
| Professional | | $1,118.80 | $2,237.60 | $3,192.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,118.80 / $1,399.14 / $3,192.77
| Professional | | $1,118.80 | $1,399.14 | $3,192.77 |