- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,464.26 / $5,464.26 / $5,464.26
| Facility | | $5,464.26 | $5,464.26 | $5,464.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,775.23 / $5,464.26 / $5,464.26
| Professional | | $2,775.23 | $5,464.26 | $5,464.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,838.14 / $4,838.14 / $4,838.14
| Professional | | $4,838.14 | $4,838.14 | $4,838.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,423.18 / $4,423.18 / $6,837.60
| Facility | | $4,423.18 | $4,423.18 | $6,837.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,228.92 / $4,423.18 / $6,187.14
| Professional | | $3,228.92 | $4,423.18 | $6,187.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,161.96 / $3,242.96 / $4,997.30
| Professional | | $2,161.96 | $3,242.96 | $4,997.30 |