- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,125.92 / $5,125.92 / $5,125.92
| Facility | | $5,125.92 | $5,125.92 | $5,125.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,603.39 / $5,125.92 / $5,125.92
| Professional | | $2,603.39 | $5,125.92 | $5,125.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,538.58 / $4,538.58 / $4,538.58
| Professional | | $4,538.58 | $4,538.58 | $4,538.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,052.23 / $4,052.23 / $6,316.78
| Facility | | $4,052.23 | $4,052.23 | $6,316.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,958.13 / $4,052.23 / $5,531.20
| Professional | | $2,958.13 | $4,052.23 | $5,531.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,856.56 / $3,042.16 / $4,291.35
| Professional | | $1,856.56 | $3,042.16 | $4,291.35 |