- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,819.82 / $5,060.81 / $13,447.30
| Facility | | $4,819.82 | $5,060.81 | $13,447.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,904.05 / $4,819.82 / $4,819.82
| Professional | | $3,904.05 | $4,819.82 | $4,819.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.74 / $2,645.45 / $2,984.61
| Facility | | $1,862.74 | $2,645.45 | $2,984.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.74 / $1,862.74 / $1,899.99
| Professional | | $1,862.74 | $1,862.74 | $1,899.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,819.82 / $4,819.82 / $4,819.82
| Facility | | $4,819.82 | $4,819.82 | $4,819.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,819.82 / $4,819.82 / $4,819.82
| Professional | | $4,819.82 | $4,819.82 | $4,819.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,100.64 / $5,684.00 / $6,266.61
| Professional | | $5,100.64 | $5,684.00 | $6,266.61 |