- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,761.02 / $2,761.02 / $4,314.09
| Facility | | $2,761.02 | $2,761.02 | $4,314.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,591.78 / $3,958.46 / $4,314.09
| Professional | | $2,591.78 | $3,958.46 | $4,314.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,817.91 / $3,817.91 / $3,817.91
| Facility | | $3,817.91 | $3,817.91 | $3,817.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,817.91 / $3,817.91 / $3,817.91
| Professional | | $3,817.91 | $3,817.91 | $3,817.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,802.84 / $2,802.84 / $2,802.84
| Facility | | $2,802.84 | $2,802.84 | $2,802.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,382.41 / $2,382.41 / $2,802.84
| Professional | | $2,382.41 | $2,382.41 | $2,802.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,491.86 / $2,457.94 / $3,887.82
| Professional | | $1,491.86 | $2,457.94 | $3,887.82 |