- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,171.78 / $5,171.78 / $5,171.78
| Facility | | $5,171.78 | $5,171.78 | $5,171.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,626.68 / $5,171.78 / $5,171.78
| Professional | | $2,626.68 | $5,171.78 | $5,171.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,579.18 / $4,579.18 / $4,579.18
| Professional | | $4,579.18 | $4,579.18 | $4,579.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,728.96 / $4,728.96 / $7,310.32
| Facility | | $4,728.96 | $4,728.96 | $7,310.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,452.14 / $4,728.96 / $6,401.17
| Professional | | $3,452.14 | $4,728.96 | $6,401.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,926.06 / $6,926.06 / $8,148.31
| Facility | | $6,926.06 | $6,926.06 | $8,148.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,032.55 / $3,069.37 / $4,698.14
| Professional | | $2,032.55 | $3,069.37 | $4,698.14 |