- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,839.83 / $3,839.83 / $6,141.85
| Facility | | $3,839.83 | $3,839.83 | $6,141.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,692.14 / $3,729.06 / $3,925.76
| Professional | | $3,692.14 | $3,729.06 | $3,925.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,692.14 / $3,692.14 / $3,692.14
| Professional | | $3,692.14 | $3,692.14 | $3,692.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,692.14 / $3,692.14 / $3,692.14
| Facility | | $3,692.14 | $3,692.14 | $3,692.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,692.14 / $3,692.14 / $3,692.14
| Professional | | $3,692.14 | $3,692.14 | $3,692.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,812.64 / $3,692.14 / $5,477.26
| Professional | | $2,812.64 | $3,692.14 | $5,477.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,507.53 / $3,692.14 / $4,098.28
| Professional | | $3,507.53 | $3,692.14 | $4,098.28 |