- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,362.39 / $3,362.39 / $5,253.74
| Facility | | $3,362.39 | $3,362.39 | $5,253.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,649.05 / $3,666.79 / $5,253.74
| Professional | | $2,649.05 | $3,666.79 | $5,253.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,780.57 / $4,780.57 / $4,780.57
| Facility | | $4,780.57 | $4,780.57 | $4,780.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,780.57 / $4,780.57 / $4,780.57
| Professional | | $4,780.57 | $4,780.57 | $4,780.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,323.97 / $3,323.97 / $3,323.97
| Facility | | $3,323.97 | $3,323.97 | $3,323.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,426.50 / $2,426.50 / $3,323.97
| Professional | | $2,426.50 | $2,426.50 | $3,323.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.65 / $2,993.29 / $4,739.38
| Professional | | $1,496.65 | $2,993.29 | $4,739.38 |