- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,833.76 / $4,833.76 / $4,833.76
| Facility | | $4,833.76 | $4,833.76 | $4,833.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,011.15 / $4,011.15 / $4,833.76
| Professional | | $4,011.15 | $4,011.15 | $4,833.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,675.25 / $7,811.58 / $7,946.59
| Professional | | $6,675.25 | $7,811.58 | $7,946.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,776.25 / $6,844.01 / $8,605.84
| Professional | | $6,776.25 | $6,844.01 | $8,605.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,117.23 / $4,833.76 / $7,013.77
| Facility | | $3,117.23 | $4,833.76 | $7,013.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.54 / $2,989.07 / $4,154.78
| Professional | | $1,494.54 | $2,989.07 | $4,154.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,473.15 / $2,769.85 / $4,154.78
| Professional | | $1,473.15 | $2,769.85 | $4,154.78 |