- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $7,762.47 / $7,762.47
| Facility | | $3,981.07 | $7,762.47 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,890.45 / $4,677.35
| Professional | | $3,715.35 | $3,890.45 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $7,413.10
| Facility | | $3,981.07 | $3,981.07 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $20,892.96
| Professional | | $3,981.07 | $3,981.07 | $20,892.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $4,677.35
| Professional | | $3,890.45 | $3,890.45 | $4,677.35 |