- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,672.47 / $5,046.26 / $8,578.64
| Facility | | $4,672.47 | $5,046.26 | $8,578.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,061.80 / $5,061.80 / $5,061.80
| Professional | | $5,061.80 | $5,061.80 | $5,061.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,617.15 / $4,128.02 / $6,546.32
| Facility | | $2,617.15 | $4,128.02 | $6,546.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,421.56 / $4,421.56 / $4,686.85
| Facility | | $4,421.56 | $4,421.56 | $4,686.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,052.03 / $4,686.85 / $4,686.85
| Professional | | $2,052.03 | $4,686.85 | $4,686.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,799.93 / $4,672.47 / $7,216.15
| Facility | | $3,799.93 | $4,672.47 | $7,216.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,672.47 / $4,672.47 / $4,687.66
| Professional | | $4,672.47 | $4,672.47 | $4,687.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,686.85 / $4,686.85 / $4,687.66
| Professional | | $4,686.85 | $4,686.85 | $4,687.66 |