- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,489.63 / $3,489.63 / $7,415.46
| Facility | | $3,489.63 | $3,489.63 | $7,415.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,780.66 / $1,780.66 / $1,780.66
| Professional | | $1,780.66 | $1,780.66 | $1,780.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,395.85 / $1,395.85 / $2,268.25
| Professional | | $1,395.85 | $1,395.85 | $2,268.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,489.63 / $3,489.63 / $3,524.53
| Professional | | $3,489.63 | $3,489.63 | $3,524.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,489.63 / $3,489.63 / $5,653.20
| Facility | | $3,489.63 | $3,489.63 | $5,653.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,780.66 / $1,780.66 / $3,489.63
| Professional | | $1,780.66 | $1,780.66 | $3,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,779.71 / $2,093.78 / $6,106.85
| Professional | | $1,779.71 | $2,093.78 | $6,106.85 |