- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,025.60 / $8,317.64
| Facility | | $6,025.60 | $6,025.60 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,073.80 / $6,025.60
| Professional | | $3,162.28 | $4,073.80 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $6,456.54
| Professional | | $4,265.80 | $4,265.80 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,801.89 / $8,912.51
| Facility | | $3,090.30 | $3,801.89 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $4,786.30
| Facility | | $4,265.80 | $4,265.80 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,884.03 / $4,786.30
| Professional | | $1,995.26 | $2,884.03 | $4,786.30 |