- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,070.66 / $3,070.66 / $4,797.89
| Facility | | $3,070.66 | $3,070.66 | $4,797.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,966.32 / $4,348.72 / $5,272.94
| Professional | | $2,966.32 | $4,348.72 | $5,272.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,246.06 / $4,246.06 / $4,246.06
| Facility | | $4,246.06 | $4,246.06 | $4,246.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,246.06 / $4,246.06 / $4,246.06
| Professional | | $4,246.06 | $4,246.06 | $4,246.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,072.36 / $4,072.36 / $4,072.36
| Facility | | $4,072.36 | $4,072.36 | $4,072.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,972.82 / $2,972.82 / $4,072.36
| Professional | | $2,972.82 | $2,972.82 | $4,072.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,774.99 / $2,733.58 / $4,102.81
| Professional | | $1,774.99 | $2,733.58 | $4,102.81 |