- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,575.27 / $4,575.27 / $4,575.27
| Facility | | $4,575.27 | $4,575.27 | $4,575.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,575.27 / $4,575.27 / $4,575.27
| Professional | | $4,575.27 | $4,575.27 | $4,575.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,773.56 / $4,773.56 / $4,773.56
| Professional | | $4,773.56 | $4,773.56 | $4,773.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,038.73 / $4,038.73 / $4,038.73
| Professional | | $4,038.73 | $4,038.73 | $4,038.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,579.42 / $5,579.42 / $17,039.21
| Professional | | $5,579.42 | $5,579.42 | $17,039.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,854.89 / $4,282.33 / $6,066.64
| Professional | | $2,854.89 | $4,282.33 | $6,066.64 |