- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $6,025.60
| Facility | | $4,365.16 | $4,365.16 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,818.38 / $4,365.16
| Professional | | $2,089.30 | $2,818.38 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $5,370.32
| Facility | | $3,890.45 | $3,890.45 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $4,677.35
| Professional | | $3,548.13 | $3,548.13 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,466.84 / $6,456.54
| Facility | | $2,290.87 | $4,466.84 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,467.37
| Facility | | $3,162.28 | $3,162.28 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,089.30 / $3,467.37
| Professional | | $1,479.11 | $2,089.30 | $3,467.37 |