- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,638.86 / $4,075.52 / $7,277.72
| Facility | | $3,638.86 | $4,075.52 | $7,277.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.82 / $3,660.83 / $3,660.83
| Professional | | $3,660.82 | $3,660.83 | $3,660.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,316.85 / $6,223.41 / $16,000.39
| Facility | | $4,316.85 | $6,223.41 | $16,000.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,638.86 / $3,660.83 / $3,660.83
| Professional | | $3,638.86 | $3,660.83 | $3,660.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,453.62 / $3,660.83 / $3,660.83
| Facility | | $3,453.62 | $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
- $3,840.94 / $5,945.19 / $11,299.15
| Professional | | $3,840.94 | $5,945.19 | $11,299.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,334.59 / $3,660.83 / $3,660.83
| Professional | | $2,334.59 | $3,660.83 | $3,660.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,320.13 / $3,652.14 / $4,648.18
| Professional | | $3,320.13 | $3,652.14 | $4,648.18 |