- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $6,456.54
| Facility | | $4,897.79 | $4,897.79 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,888.44 / $8,317.64
| Professional | | $4,466.84 | $5,888.44 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $7,244.36
| Facility | | $4,466.84 | $4,466.84 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,466.84 / $7,244.36
| Professional | | $4,265.80 | $4,466.84 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $6,456.54 / $15,848.93
| Facility | | $4,897.79 | $6,456.54 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $6,025.60 / $7,762.47
| Professional | | $4,786.30 | $6,025.60 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,890.45 / $6,025.60
| Facility | | $1,698.24 | $3,890.45 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,165.95 / $8,317.64
| Professional | | $4,365.16 | $6,165.95 | $8,317.64 |