- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,971.34 / $6,114.75 / $13,046.30
| Facility | | $4,971.34 | $6,114.75 | $13,046.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,035.55 / $4,854.35 / $4,971.34
| Professional | | $4,035.55 | $4,854.35 | $4,971.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,971.34 / $5,160.59 / $6,433.49
| Facility | | $4,971.34 | $5,160.59 | $6,433.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,971.34 / $4,971.34 / $4,971.34
| Professional | | $4,971.34 | $4,971.34 | $4,971.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,361.25 / $5,848.63 / $6,302.87
| Professional | | $5,361.25 | $5,848.63 | $6,302.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,104.58 / $8,702.00 / $13,785.00
| Facility | | $3,104.58 | $8,702.00 | $13,785.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,971.34 / $4,971.34 / $4,971.34
| Professional | | $4,971.34 | $4,971.34 | $4,971.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,873.85 / $5,117.55 / $5,799.89
| Professional | | $4,873.85 | $5,117.55 | $5,799.89 |