- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,428.88 / $3,428.88 / $4,608.39
| Facility | | $3,428.88 | $3,428.88 | $4,608.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,743.10 / $2,743.10 / $3,428.88
| Professional | | $2,743.10 | $2,743.10 | $3,428.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,914.55 / $2,914.55 / $2,914.55
| Facility | | $2,914.55 | $2,914.55 | $2,914.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,914.55 / $2,914.55 / $2,914.55
| Professional | | $2,914.55 | $2,914.55 | $2,914.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,743.10 / $3,428.88 / $4,311.13
| Facility | | $2,743.10 | $3,428.88 | $4,311.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,857.40 / $2,857.40 / $13,029.74
| Professional | | $2,857.40 | $2,857.40 | $13,029.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,857.40 / $2,857.40 / $3,428.88
| Professional | | $2,857.40 | $2,857.40 | $3,428.88 |