- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,817.28 / $10,639.40 / $14,336.80
| Facility | | $3,817.28 | $10,639.40 | $14,336.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,817.28 / $3,817.28 / $3,817.28
| Professional | | $3,817.28 | $3,817.28 | $3,817.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,567.62 / $3,567.62 / $3,567.62
| Professional | | $3,567.62 | $3,567.62 | $3,567.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,601.20 / $3,601.20 / $3,817.28
| Facility | | $3,601.20 | $3,601.20 | $3,817.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,244.69 / $3,244.69 / $3,817.28
| Professional | | $3,244.69 | $3,244.69 | $3,817.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,779.11 / $4,046.32 / $5,619.11
| Professional | | $3,779.11 | $4,046.32 | $5,619.11 |