- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,031.20 / $5,031.20 / $5,031.20
| Facility | | $5,031.20 | $5,031.20 | $5,031.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,031.20 / $5,031.20 / $5,031.20
| Facility | | $5,031.20 | $5,031.20 | $5,031.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,031.20 / $5,031.20 / $5,031.20
| Professional | | $5,031.20 | $5,031.20 | $5,031.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,270.28 / $3,433.79 / $3,816.42
| Facility | | $3,270.28 | $3,433.79 | $3,816.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,153.38 / $2,291.35 / $6,029.45
| Professional | | $2,153.38 | $2,291.35 | $6,029.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,113.10 / $3,018.72 / $8,553.04
| Professional | | $2,113.10 | $3,018.72 | $8,553.04 |