- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,314.54 / $2,314.54 / $3,616.47
| Facility | | $2,314.54 | $2,314.54 | $3,616.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,172.67 / $3,616.47 / $4,487.24
| Professional | | $2,172.67 | $3,616.47 | $4,487.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,200.52 / $3,200.52 / $3,200.52
| Facility | | $3,200.52 | $3,200.52 | $3,200.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,200.52 / $3,200.52 / $3,200.52
| Professional | | $3,200.52 | $3,200.52 | $3,200.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,148.57 / $3,148.57 / $3,148.57
| Facility | | $3,148.57 | $3,148.57 | $3,148.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,298.46 / $2,298.46 / $3,148.57
| Professional | | $2,298.46 | $2,298.46 | $3,148.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,373.64 / $2,060.46 / $3,175.12
| Professional | | $1,373.64 | $2,060.46 | $3,175.12 |