- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $6,456.54
| Facility | | $4,677.35 | $4,677.35 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,090.30 / $4,677.35
| Professional | | $2,187.76 | $3,090.30 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $5,011.87
| Professional | | $3,715.35 | $3,715.35 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,786.30 / $6,760.83
| Facility | | $2,398.83 | $4,786.30 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,715.35
| Facility | | $3,311.31 | $3,311.31 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,187.76 / $3,715.35
| Professional | | $1,548.82 | $2,187.76 | $3,715.35 |