- 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
- $2,137.96 / $2,570.40 / $4,073.80
| Professional | | $2,137.96 | $2,570.40 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $4,365.16
| Professional | | $3,235.94 | $3,235.94 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,511.89 / $5,888.44
| Facility | | $2,089.30 | $2,511.89 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $3,235.94
| Facility | | $2,884.03 | $2,884.03 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,905.46 / $3,235.94
| Professional | | $1,348.96 | $1,905.46 | $3,235.94 |