- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $5,495.41
| Facility | | $3,467.37 | $3,467.37 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,467.37 / $5,623.41
| Professional | | $2,691.53 | $3,467.37 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Facility | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Professional | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $4,365.16
| Facility | | $4,365.16 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $4,365.16
| Professional | | $3,162.28 | $3,162.28 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,011.87 / $8,511.38
| Facility | | $4,073.80 | $5,011.87 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,019.95 / $4,786.30
| Professional | | $2,089.30 | $3,019.95 | $4,786.30 |