- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,660.82 / $4,548.58 / $8,878.82
| Facility | | $3,660.82 | $4,548.58 | $8,878.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,660.83 / $3,697.44
| Professional | | $3,660.83 | $3,660.83 | $3,697.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,004.40 / $3,740.54 / $4,840.68
| Facility | | $3,004.40 | $3,740.54 | $4,840.68 |
- 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
- $1,165.00 / $8,702.00 / $13,785.00
| Facility | | $1,165.00 | $8,702.00 | $13,785.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,189.89 / $3,494.17 / $3,494.17
| Professional | | $3,189.89 | $3,494.17 | $3,494.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,660.83 / $4,486.16
| Professional | | $3,660.83 | $3,660.83 | $4,486.16 |