- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,638.86 / $3,770.66 / $8,041.88
| Facility | | $3,638.86 | $3,770.66 | $8,041.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.82 / $3,660.83 / $4,403.02
| Professional | | $3,660.82 | $3,660.83 | $4,403.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $215.75 / $345.47 / $3,670.25
| Facility | | $215.75 | $345.47 | $3,670.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,670.25 / $3,670.25 / $3,743.66
| Professional | | $3,670.25 | $3,670.25 | $3,743.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $40.00
| Facility | | $40.00 | $40.00 | $40.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,453.62 / $3,453.62 / $3,660.83
| Facility | | $3,453.62 | $3,453.62 | $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
- $3,587.61 / $3,660.83 / $4,611.45
| Professional | | $3,587.61 | $3,660.83 | $4,611.45 |