- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,469.36 / $2,469.36 / $4,294.16
| Facility | | $2,469.36 | $2,469.36 | $4,294.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,294.16 / $4,294.16 / $4,294.16
| Professional | | $4,294.16 | $4,294.16 | $4,294.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,041.56 / $4,041.56 / $4,041.56
| Professional | | $4,041.56 | $4,041.56 | $4,041.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,294.16 / $4,294.16 / $4,294.16
| Facility | | $4,294.16 | $4,294.16 | $4,294.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,294.16 / $4,294.16 / $4,294.16
| Professional | | $4,294.16 | $4,294.16 | $4,294.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,079.45 / $4,079.45 / $6,091.75
| Professional | | $4,079.45 | $4,079.45 | $6,091.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,209.96 / $4,209.96 / $6,823.42
| Professional | | $4,209.96 | $4,209.96 | $6,823.42 |