- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $3,890.45
| Facility | | $2,511.89 | $2,511.89 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,630.27 / $4,466.84
| Professional | | $1,949.84 | $2,630.27 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Facility | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Professional | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $3,801.89
| Facility | | $3,801.89 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $3,801.89
| Professional | | $2,754.23 | $2,754.23 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,548.13 / $6,025.60
| Facility | | $2,951.21 | $3,548.13 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,187.76 / $3,467.37
| Professional | | $1,479.11 | $2,187.76 | $3,467.37 |