- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,474.46 / $3,474.46 / $5,428.84
| Facility | | $3,474.46 | $3,474.46 | $5,428.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,474.46 / $5,243.12 / $6,299.24
| Professional | | $3,474.46 | $5,243.12 | $6,299.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,804.43 / $4,804.43 / $4,804.43
| Facility | | $4,804.43 | $4,804.43 | $4,804.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,804.43 / $4,804.43 / $4,804.43
| Professional | | $4,804.43 | $4,804.43 | $4,804.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,865.01 / $4,865.01 / $4,865.01
| Facility | | $4,865.01 | $4,865.01 | $4,865.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,551.46 / $3,551.46 / $4,865.01
| Professional | | $3,551.46 | $3,551.46 | $4,865.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,320.94 / $5,320.94 / $5,320.94
| Facility | | $5,320.94 | $5,320.94 | $5,320.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,053.08 / $3,093.05 / $4,892.39
| Professional | | $2,053.08 | $3,093.05 | $4,892.39 |