- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,900.96 / $3,947.40 / $6,391.61
| Facility | | $3,900.96 | $3,947.40 | $6,391.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,761.64 / $3,854.52 / $3,947.40
| Professional | | $3,761.64 | $3,854.52 | $3,947.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,914.61 / $4,116.41 / $8,685.44
| Facility | | $1,914.61 | $4,116.41 | $8,685.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,870.00 / $3,966.75 / $6,165.19
| Professional | | $3,870.00 | $3,966.75 | $6,165.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,947.40 / $3,947.40 / $3,947.40
| Facility | | $3,947.40 | $3,947.40 | $3,947.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,947.40 / $3,947.40 / $3,947.40
| Professional | | $3,947.40 | $3,947.40 | $3,947.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,870.00 / $3,870.00 / $4,644.00
| Professional | | $3,870.00 | $3,870.00 | $4,644.00 |