- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,638.02 / $4,638.02 / $4,638.02
| Facility | | $4,638.02 | $4,638.02 | $4,638.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,355.59 / $4,638.02 / $4,638.02
| Professional | | $2,355.59 | $4,638.02 | $4,638.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,728.42 / $3,728.42 / $5,762.36
| Facility | | $3,728.42 | $3,728.42 | $5,762.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,721.75 / $3,728.42 / $5,045.72
| Professional | | $2,721.75 | $3,728.42 | $5,045.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,708.34 / $2,752.59 / $3,948.74
| Professional | | $1,708.34 | $2,752.59 | $3,948.74 |