- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,781.84 / $2,781.84 / $4,433.55
| Facility | | $2,781.84 | $2,781.84 | $4,433.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,611.31 / $3,173.03 / $4,433.55
| Professional | | $2,611.31 | $3,173.03 | $4,433.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,846.68 / $3,846.68 / $3,846.68
| Facility | | $3,846.68 | $3,846.68 | $3,846.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,846.68 / $3,846.68 / $3,846.68
| Professional | | $3,846.68 | $3,846.68 | $3,846.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,756.64 / $2,756.64 / $2,756.64
| Facility | | $2,756.64 | $2,756.64 | $2,756.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,012.35 / $2,012.35 / $4,137.60
| Professional | | $2,012.35 | $2,012.35 | $4,137.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,467.28 / $2,309.32 / $3,696.66
| Professional | | $1,467.28 | $2,309.32 | $3,696.66 |