- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $5,128.61
| Facility | | $3,715.35 | $3,715.35 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,454.71 / $3,715.35
| Professional | | $1,949.84 | $2,454.71 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $3,981.07
| Professional | | $2,951.21 | $2,951.21 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,801.89 / $5,370.32
| Facility | | $1,905.46 | $3,801.89 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $2,951.21
| Facility | | $2,630.27 | $2,630.27 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,737.80 / $2,951.21
| Professional | | $1,230.27 | $1,737.80 | $2,951.21 |