- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,638.86 / $3,929.97 / $6,680.95
| Facility | | $3,638.86 | $3,929.97 | $6,680.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,953.70 / $3,953.70 / $3,953.70
| Professional | | $3,953.70 | $3,953.70 | $3,953.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $858.75 / $1,354.50 / $2,148.00
| Facility | | $858.75 | $1,354.50 | $2,148.00 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $2,512.55 / $3,638.86 / $5,619.86
| Facility | | $2,512.55 | $3,638.86 | $5,619.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,565.32 / $3,638.86 / $3,660.83
| Professional | | $3,565.32 | $3,638.86 | $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 |