- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,043.59 / $5,043.59 / $5,043.59
| Facility | | $5,043.59 | $5,043.59 | $5,043.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,561.57 / $5,043.59 / $5,043.59
| Professional | | $2,561.57 | $5,043.59 | $5,043.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,465.68 / $4,465.68 / $4,465.68
| Professional | | $4,465.68 | $4,465.68 | $4,465.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,323.97 / $3,323.97 / $5,251.23
| Facility | | $3,323.97 | $3,323.97 | $5,251.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,426.50 / $3,323.97 / $4,598.16
| Professional | | $2,426.50 | $3,323.97 | $4,598.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.65 / $2,993.29 / $4,051.45
| Professional | | $1,496.65 | $2,993.29 | $4,051.45 |