- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,660.83 / $6,430.22 / $13,827.70
| Facility | | $3,660.83 | $6,430.22 | $13,827.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,660.83 / $3,660.83
| Professional | | $3,660.83 | $3,660.83 | $3,660.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,638.86 / $5,365.70 / $9,072.91
| Professional | | $3,638.86 | $5,365.70 | $9,072.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,453.62 / $3,453.62 / $3,660.83
| Facility | | $3,453.62 | $3,453.62 | $3,660.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,111.71 / $3,111.71 / $3,660.83
| Professional | | $3,111.71 | $3,111.71 | $3,660.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,331.36 / $3,660.83 / $5,933.40
| Professional | | $3,331.36 | $3,660.83 | $5,933.40 |