- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $6,760.83
| Facility | | $4,897.79 | $4,897.79 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,311.31 / $4,897.79
| Professional | | $2,570.40 | $3,311.31 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $5,248.07
| Professional | | $3,467.37 | $3,467.37 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $5,754.40 / $7,244.36
| Facility | | $2,511.89 | $5,754.40 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,890.45
| Facility | | $3,467.37 | $3,467.37 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,344.23 / $3,890.45
| Professional | | $1,621.81 | $2,344.23 | $3,890.45 |