- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,638.86 / $3,638.86 / $6,430.22
| Facility | | $3,638.86 | $3,638.86 | $6,430.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.82 / $3,660.83 / $4,657.74
| Professional | | $3,660.82 | $3,660.83 | $4,657.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,638.86 / $3,638.86 / $3,660.84
| Professional | | $3,638.86 | $3,638.86 | $3,660.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,660.83 / $4,662.38
| Professional | | $3,660.83 | $3,660.83 | $4,662.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,660.83 / $4,150.31
| Professional | | $3,660.83 | $3,660.83 | $4,150.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,660.83 / $3,880.48
| Professional | | $3,660.83 | $3,660.83 | $3,880.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,550.05 / $3,550.05 / $3,550.05
| Professional | | $3,550.05 | $3,550.05 | $3,550.05 |