- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,754.40 / $21,877.62
| Facility | | $4,786.30 | $5,754.40 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,011.87 / $5,128.61
| Professional | | $4,786.30 | $5,011.87 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $6,760.83 / $11,748.98
| Facility | | $3,981.07 | $6,760.83 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,370.32 / $7,585.78
| Professional | | $4,786.30 | $5,370.32 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $15,135.61
| Facility | | $5,128.61 | $5,128.61 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $6,165.95
| Professional | | $5,128.61 | $5,128.61 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,511.89 / $3,981.07
| Facility | | $2,041.74 | $2,511.89 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,754.40
| Professional | | $5,011.87 | $5,011.87 | $5,754.40 |