- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,466.84 / $8,128.31
| Facility | | $3,715.35 | $4,466.84 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,073.80 / $4,466.84
| Professional | | $3,548.13 | $4,073.80 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $6,309.57 / $13,182.57
| Facility | | $3,548.13 | $6,309.57 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $4,073.80
| Professional | | $3,467.37 | $3,467.37 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,848.93 / $15,848.93 / $15,848.93
| Professional | | $15,848.93 | $15,848.93 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,715.35 / $4,073.80
| Professional | | $3,548.13 | $3,715.35 | $4,073.80 |