- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,909.76 / $3,909.76 / $4,139.85
| Facility | | $3,909.76 | $3,909.76 | $4,139.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,135.72 / $3,688.02 / $4,681.80
| Professional | | $3,135.72 | $3,688.02 | $4,681.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,346.70 / $7,514.08 / $7,514.08
| Facility | | $6,346.70 | $7,514.08 | $7,514.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,853.15 / $4,479.81 / $4,672.39
| Professional | | $3,853.15 | $4,479.81 | $4,672.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,461.85 / $3,461.85 / $3,461.85
| Facility | | $3,461.85 | $3,461.85 | $3,461.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $544.79 / $3,461.85 / $5,402.12
| Professional | | $544.79 | $3,461.85 | $5,402.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,405.94 / $3,135.54 / $5,200.30
| Professional | | $2,405.94 | $3,135.54 | $5,200.30 |