- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,648.43 / $2,648.43 / $4,138.17
| Facility | | $2,648.43 | $2,648.43 | $4,138.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,455.67 / $3,600.11 / $4,268.32
| Professional | | $2,455.67 | $3,600.11 | $4,268.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,662.21 / $3,662.21 / $3,662.21
| Facility | | $3,662.21 | $3,662.21 | $3,662.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,662.21 / $3,662.21 / $3,662.21
| Professional | | $3,662.21 | $3,662.21 | $3,662.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,001.57 / $3,001.57 / $3,001.57
| Facility | | $3,001.57 | $3,001.57 | $3,001.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,191.15 / $2,191.15 / $3,001.57
| Professional | | $2,191.15 | $2,191.15 | $3,001.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,316.73 / $2,361.54 / $3,633.14
| Professional | | $1,316.73 | $2,361.54 | $3,633.14 |