- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $8,128.31 / $13,803.84
| Facility | | $4,786.30 | $8,128.31 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $6,760.83
| Professional | | $4,786.30 | $4,786.30 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $6,606.93 / $13,182.57
| Facility | | $4,897.79 | $6,606.93 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,786.30 / $6,456.54
| Professional | | $4,677.35 | $4,786.30 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,786.30 / $7,079.46
| Facility | | $4,466.84 | $4,786.30 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,897.79 / $6,165.95
| Professional | | $4,786.30 | $4,897.79 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,786.30 / $8,317.64
| Facility | | $3,890.45 | $4,786.30 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,786.30 / $6,165.95
| Professional | | $4,677.35 | $4,786.30 | $6,165.95 |