- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,081.45 / $4,628.03 / $10,130.70
| Facility | | $3,081.45 | $4,628.03 | $10,130.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,081.45 / $3,081.45
| Professional | | $3,081.45 | $3,081.45 | $3,081.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,370.28 / $4,592.59 / $9,139.87
| Facility | | $2,370.28 | $4,592.59 | $9,139.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,021.04 / $3,021.04 / $3,081.45
| Professional | | $3,021.04 | $3,021.04 | $3,081.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,081.45 / $3,081.45
| Facility | | $3,081.45 | $3,081.45 | $3,081.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,081.45 / $3,081.45
| Professional | | $3,081.45 | $3,081.45 | $3,081.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,388.77 / $2,752.08 / $3,081.45
| Professional | | $2,388.77 | $2,752.08 | $3,081.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,718.94 / $3,021.04 / $3,335.22
| Professional | | $2,718.94 | $3,021.04 | $3,335.22 |