- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,807.27 / $5,683.82 / $10,230.20
| Facility | | $3,807.27 | $5,683.82 | $10,230.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,807.27 / $3,807.27 / $3,807.27
| Professional | | $3,807.27 | $3,807.27 | $3,807.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,262.90 / $5,518.70 / $10,973.34
| Facility | | $3,262.90 | $5,518.70 | $10,973.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,660.83 / $3,660.83
| Professional | | $3,660.83 | $3,660.83 | $3,660.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,660.83 / $3,660.83
| Facility | | $3,660.83 | $3,660.83 | $3,660.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,660.83 / $3,660.83
| Professional | | $3,660.83 | $3,660.83 | $3,660.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,798.98 / $3,798.98 / $4,579.50
| Professional | | $3,798.98 | $3,798.98 | $4,579.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,294.75 / $3,660.83 / $4,242.53
| Professional | | $3,294.75 | $3,660.83 | $4,242.53 |