- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,493.83 / $2,493.83 / $3,896.61
| Facility | | $2,493.83 | $2,493.83 | $3,896.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,340.96 / $3,575.37 / $3,896.61
| Professional | | $2,340.96 | $3,575.37 | $3,896.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,448.45 / $3,448.45 / $3,448.45
| Facility | | $3,448.45 | $3,448.45 | $3,448.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,448.45 / $3,448.45 / $3,448.45
| Professional | | $3,448.45 | $3,448.45 | $3,448.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,600.52 / $3,600.52 / $3,600.52
| Facility | | $3,600.52 | $3,600.52 | $3,600.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,060.44 / $3,060.44 / $3,600.52
| Professional | | $3,060.44 | $3,060.44 | $3,600.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,347.50 / $2,220.08 / $3,114.68
| Professional | | $1,347.50 | $2,220.08 | $3,114.68 |