- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,780.79 / $2,780.79 / $4,344.97
| Facility | | $2,780.79 | $2,780.79 | $4,344.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,610.34 / $4,043.03 / $4,344.97
| Professional | | $2,610.34 | $4,043.03 | $4,344.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,845.25 / $3,845.25 / $3,845.25
| Facility | | $3,845.25 | $3,845.25 | $3,845.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,845.25 / $3,845.25 / $3,845.25
| Professional | | $3,845.25 | $3,845.25 | $3,845.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,801.20 / $2,801.20 / $2,801.20
| Facility | | $2,801.20 | $2,801.20 | $2,801.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,044.88 / $2,044.88 / $4,388.22
| Professional | | $2,044.88 | $2,044.88 | $4,388.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,466.37 / $2,475.53 / $3,389.45
| Professional | | $1,466.37 | $2,475.53 | $3,389.45 |