- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,625.24 / $3,625.24 / $5,075.34
| Facility | | $3,625.24 | $3,625.24 | $5,075.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,625.24 / $3,625.24 / $3,625.24
| Professional | | $3,625.24 | $3,625.24 | $3,625.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,157.26 / $1,357.85 / $3,262.72
| Facility | | $1,157.26 | $1,357.85 | $3,262.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,262.72 / $3,262.72 / $3,327.97
| Professional | | $3,262.72 | $3,262.72 | $3,327.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,081.45 / $3,081.45
| Facility | | $3,081.45 | $3,081.45 | $3,081.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,081.45 / $3,081.45
| Professional | | $3,081.45 | $3,081.45 | $3,081.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,021.04 / $3,021.04 / $3,776.30
| Professional | | $3,021.04 | $3,021.04 | $3,776.30 |