- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,888.44 / $10,471.29
| Facility | | $4,677.35 | $5,888.44 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,897.79 / $5,888.44
| Professional | | $4,677.35 | $4,897.79 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,248.07 / $6,606.93
| Professional | | $5,011.87 | $5,248.07 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,128.61 / $8,128.31
| Facility | | $4,073.80 | $5,128.61 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $5,370.32 / $6,025.60
| Professional | | $4,897.79 | $5,370.32 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $5,011.87 / $5,888.44
| Professional | | $4,897.79 | $5,011.87 | $5,888.44 |