- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $4,570.88 / $5,128.61
| Facility | | $4,570.88 | $4,570.88 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,235.94 / $5,128.61
| Professional | | $2,290.87 | $3,235.94 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $6,918.31 / $7,585.78
| Professional | | $5,248.07 | $6,918.31 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,079.46 / $8,912.51
| Professional | | $7,079.46 | $7,079.46 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,370.32 / $27,542.29
| Facility | | $2,290.87 | $5,370.32 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,162.28 / $6,165.95
| Professional | | $2,290.87 | $3,162.28 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $8,511.38 / $8,511.38
| Facility | | $3,467.37 | $8,511.38 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,890.45 / $6,456.54
| Professional | | $2,041.74 | $3,890.45 | $6,456.54 |