- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,082.38 / $4,082.38 / $4,082.38
| Facility | | $4,082.38 | $4,082.38 | $4,082.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,073.39 / $4,082.38 / $4,082.38
| Professional | | $2,073.39 | $4,082.38 | $4,082.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,886.72 / $2,886.72 / $4,830.29
| Facility | | $2,886.72 | $2,886.72 | $4,830.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,107.31 / $2,886.72 / $4,229.57
| Professional | | $2,107.31 | $2,886.72 | $4,229.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,890.35 / $4,890.35 / $5,753.36
| Facility | | $4,890.35 | $4,890.35 | $5,753.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,435.14 / $2,422.83 / $3,335.43
| Professional | | $1,435.14 | $2,422.83 | $3,335.43 |