- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,128.61 / $10,964.78
| Facility | | $5,011.87 | $5,128.61 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $5,370.32
| Professional | | $4,897.79 | $4,897.79 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,122.02
| Facility | | $1,122.02 | $1,122.02 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,148.15
| Professional | | $1,122.02 | $1,122.02 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $4,897.79
| Facility | | $4,677.35 | $4,677.35 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $4,897.79
| Professional | | $4,897.79 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,348.96 / $4,897.79
| Facility | | $1,047.13 | $1,348.96 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $4,897.79 / $5,128.61
| Professional | | $1,047.13 | $4,897.79 | $5,128.61 |