- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,392.10 / $4,392.10 / $4,392.10
| Facility | | $4,392.10 | $4,392.10 | $4,392.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,230.69 / $4,392.10 / $4,392.10
| Professional | | $2,230.69 | $4,392.10 | $4,392.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,888.84 / $3,888.84 / $3,888.84
| Professional | | $3,888.84 | $3,888.84 | $3,888.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,745.37 / $3,745.37 / $5,789.81
| Facility | | $3,745.37 | $3,745.37 | $5,789.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,734.12 / $2,734.12 / $6,712.13
| Professional | | $2,734.12 | $2,734.12 | $6,712.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,734.35 / $2,748.59 / $4,153.96
| Professional | | $1,734.35 | $2,748.59 | $4,153.96 |