- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,638.86 / $4,730.52 / $7,732.58
| Facility | | $3,638.86 | $4,730.52 | $7,732.58 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $4,397.82 / $4,397.82 / $4,397.82
| Professional | | $4,397.82 | $4,397.82 | $4,397.82 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $4,742.55 / $17,826.59 / $18,304.15
| Facility | | $4,742.55 | $17,826.59 | $18,304.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,660.83 / $3,919.73
| Professional | | $3,660.83 | $3,660.83 | $3,919.73 |