- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,634.62 / $2,634.62 / $4,116.59
| Facility | | $2,634.62 | $2,634.62 | $4,116.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,613.06 / $3,830.83 / $4,917.77
| Professional | | $2,613.06 | $3,830.83 | $4,917.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,643.11 / $3,643.11 / $3,643.11
| Facility | | $3,643.11 | $3,643.11 | $3,643.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,643.11 / $3,643.11 / $3,643.11
| Professional | | $3,643.11 | $3,643.11 | $3,643.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,798.08 / $3,798.08 / $3,798.08
| Facility | | $3,798.08 | $3,798.08 | $3,798.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,772.60 / $2,772.60 / $3,798.08
| Professional | | $2,772.60 | $2,772.60 | $3,798.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,563.60 / $2,345.41 / $3,614.20
| Professional | | $1,563.60 | $2,345.41 | $3,614.20 |