- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,784.56 / $3,968.56 / $4,478.32
| Facility | | $3,784.56 | $3,968.56 | $4,478.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,947.82 / $3,784.56 / $4,790.64
| Professional | | $2,947.82 | $3,784.56 | $4,790.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,428.68 / $4,428.68 / $8,547.35
| Facility | | $4,428.68 | $4,428.68 | $8,547.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,086.53 / $4,428.68 / $5,504.51
| Professional | | $4,086.53 | $4,428.68 | $5,504.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $422.50 / $422.50 / $4,356.07
| Facility | | $422.50 | $422.50 | $4,356.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.50 / $4,550.34 / $6,708.75
| Professional | | $422.50 | $4,550.34 | $6,708.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,393.83 / $3,123.63 / $5,453.90
| Professional | | $2,393.83 | $3,123.63 | $5,453.90 |