- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,489.94 / $3,489.94 / $5,453.03
| Facility | | $3,489.94 | $3,489.94 | $5,453.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,295.81 / $5,453.03 / $5,653.62
| Professional | | $3,295.81 | $5,453.03 | $5,653.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,825.85 / $4,825.85 / $4,825.85
| Facility | | $4,825.85 | $4,825.85 | $4,825.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,825.85 / $4,825.85 / $4,825.85
| Professional | | $4,825.85 | $4,825.85 | $4,825.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,366.38 / $4,366.38 / $4,366.38
| Facility | | $4,366.38 | $4,366.38 | $4,366.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,187.46 / $3,187.46 / $4,366.38
| Professional | | $3,187.46 | $3,187.46 | $4,366.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,071.23 / $3,106.84 / $4,787.54
| Professional | | $2,071.23 | $3,106.84 | $4,787.54 |