- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,762.80 / $3,762.80 / $3,762.80
| Facility | | $3,762.80 | $3,762.80 | $3,762.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,762.80 / $4,408.78 / $6,454.65
| Professional | | $3,762.80 | $4,408.78 | $6,454.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,687.89 / $5,687.89 / $9,831.56
| Facility | | $5,687.89 | $5,687.89 | $9,831.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,834.71 / $4,834.71 / $8,608.86
| Professional | | $4,834.71 | $4,834.71 | $8,608.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,981.86 / $9,045.04 / $12,879.34
| Professional | | $8,981.86 | $9,045.04 | $12,879.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,539.81 / $6,539.81 / $6,539.81
| Professional | | $6,539.81 | $6,539.81 | $6,539.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,616.93 / $5,624.96 / $9,831.56
| Professional | | $4,616.93 | $5,624.96 | $9,831.56 |