- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,460.32 / $2,460.32 / $3,844.25
| Facility | | $2,460.32 | $2,460.32 | $3,844.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,309.51 / $3,675.58 / $3,844.25
| Professional | | $2,309.51 | $3,675.58 | $3,844.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,402.10 / $3,402.10 / $3,402.10
| Facility | | $3,402.10 | $3,402.10 | $3,402.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,402.10 / $3,402.10 / $3,402.10
| Professional | | $3,402.10 | $3,402.10 | $3,402.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,728.17 / $2,728.17 / $2,728.17
| Facility | | $2,728.17 | $2,728.17 | $2,728.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,991.56 / $1,991.56 / $3,946.36
| Professional | | $1,991.56 | $1,991.56 | $3,946.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.72 / $2,190.25 / $3,464.39
| Professional | | $1,318.72 | $2,190.25 | $3,464.39 |