- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,471.78 / $2,471.78 / $3,862.16
| Facility | | $2,471.78 | $2,471.78 | $3,862.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,320.27 / $3,593.72 / $3,862.16
| Professional | | $2,320.27 | $3,593.72 | $3,862.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,308.03 / $3,308.03 / $3,308.03
| Professional | | $3,308.03 | $3,308.03 | $3,308.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,198.17 / $4,198.17 / $4,198.17
| Facility | | $4,198.17 | $4,198.17 | $4,198.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,198.17 / $4,198.17 / $4,198.17
| Professional | | $4,198.17 | $4,198.17 | $4,198.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,448.80 / $2,448.80 / $2,448.80
| Facility | | $2,448.80 | $2,448.80 | $2,448.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,787.62 / $1,787.62 / $2,448.80
| Professional | | $1,787.62 | $1,787.62 | $2,448.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,303.42 / $2,200.44 / $3,012.78
| Professional | | $1,303.42 | $2,200.44 | $3,012.78 |