- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $6,309.57 / $10,715.19
| Facility | | $3,801.89 | $6,309.57 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $4,897.79
| Professional | | $3,801.89 | $3,801.89 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,128.61 / $10,471.29
| Facility | | $3,981.07 | $5,128.61 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $5,128.61
| Professional | | $3,801.89 | $3,801.89 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,801.89 / $5,248.07
| Facility | | $3,548.13 | $3,801.89 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,890.45 / $4,897.79
| Professional | | $3,801.89 | $3,890.45 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,801.89 / $6,309.57
| Facility | | $3,467.37 | $3,801.89 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,981.07 / $4,677.35
| Professional | | $3,801.89 | $3,981.07 | $4,677.35 |