- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $5,495.41 / $9,772.37
| Facility | | $4,897.79 | $5,495.41 | $9,772.37 |
- 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
- $6,760.83 / $12,882.50 / $21,379.62
| Facility | | $6,760.83 | $12,882.50 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $5,623.41
| Professional | | $4,897.79 | $4,897.79 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,897.79 / $4,897.79
| Facility | | $4,677.35 | $4,897.79 | $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
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $8,128.31 / $9,332.54
| Professional | | $4,897.79 | $8,128.31 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $7,585.78
| Professional | | $4,897.79 | $4,897.79 | $7,585.78 |