- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,458.82 / $3,458.82 / $3,458.82
| Facility | | $3,458.82 | $3,458.82 | $3,458.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,414.13 / $3,458.82 / $3,720.13
| Professional | | $3,414.13 | $3,458.82 | $3,720.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,584.89 / $9,522.48 / $12,343.96
| Facility | | $4,584.89 | $9,522.48 | $12,343.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,584.89 / $5,065.20 / $8,683.20
| Professional | | $4,584.89 | $5,065.20 | $8,683.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,063.89 / $4,063.89 / $8,479.69
| Facility | | $4,063.89 | $4,063.89 | $8,479.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,454.31 / $4,063.89 / $32,202.18
| Professional | | $3,454.31 | $4,063.89 | $32,202.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,519.01 / $4,240.72 / $5,891.36
| Professional | | $3,519.01 | $4,240.72 | $5,891.36 |