- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $4,570.88 / $6,309.57
| Facility | | $4,570.88 | $4,570.88 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,090.30 / $4,570.88
| Professional | | $2,398.83 | $3,090.30 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $5,623.41
| Facility | | $4,073.80 | $4,073.80 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $4,897.79
| Professional | | $3,235.94 | $3,235.94 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,884.03 / $6,760.83
| Facility | | $2,344.23 | $2,884.03 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,630.78
| Facility | | $3,235.94 | $3,235.94 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,137.96 / $3,630.78
| Professional | | $1,513.56 | $2,137.96 | $3,630.78 |