- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,268.63 / $4,268.63 / $4,268.63
| Facility | | $4,268.63 | $4,268.63 | $4,268.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,268.63 / $4,671.62 / $6,277.70
| Professional | | $4,268.63 | $4,671.62 | $6,277.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,692.77 / $8,231.75 / $10,737.06
| Facility | | $6,692.77 | $8,231.75 | $10,737.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,551.49 / $7,551.49 / $13,290.93
| Facility | | $7,551.49 | $7,551.49 | $13,290.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,418.77 / $7,551.49 / $40,025.23
| Professional | | $6,418.77 | $7,551.49 | $40,025.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,764.02 / $10,592.34 / $15,131.91
| Professional | | $4,764.02 | $10,592.34 | $15,131.91 |