- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,722.17 / $3,739.65 / $5,616.58
| Facility | | $1,722.17 | $3,739.65 | $5,616.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,739.65 / $3,739.65 / $3,739.65
| Professional | | $3,739.65 | $3,739.65 | $3,739.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.73 / $5,573.55 / $10,989.82
| Facility | | $707.73 | $5,573.55 | $10,989.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,666.33 / $3,666.33 / $3,666.33
| Professional | | $3,666.33 | $3,666.33 | $3,666.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,739.65 / $3,739.65 / $3,739.65
| Facility | | $3,739.65 | $3,739.65 | $3,739.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,739.65 / $3,739.65 / $3,739.65
| Professional | | $3,739.65 | $3,739.65 | $3,739.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $379.53 / $379.53 / $379.53
| Professional | | $379.53 | $379.53 | $379.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,486.68 / $3,666.33 / $4,047.62
| Professional | | $3,486.68 | $3,666.33 | $4,047.62 |