- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,447.85 / $3,447.85 / $5,387.27
| Facility | | $3,447.85 | $3,447.85 | $5,387.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,447.85 / $5,381.58 / $6,123.10
| Professional | | $3,447.85 | $5,381.58 | $6,123.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,767.64 / $4,767.64 / $4,767.64
| Facility | | $4,767.64 | $4,767.64 | $4,767.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,767.64 / $4,767.64 / $4,767.64
| Professional | | $4,767.64 | $4,767.64 | $4,767.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,728.96 / $4,728.96 / $4,728.96
| Facility | | $4,728.96 | $4,728.96 | $4,728.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,452.14 / $3,452.14 / $4,728.96
| Professional | | $3,452.14 | $3,452.14 | $4,728.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,926.06 / $8,148.31 / $9,777.96
| Facility | | $6,926.06 | $8,148.31 | $9,777.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,032.55 / $3,069.37 / $4,698.14
| Professional | | $2,032.55 | $3,069.37 | $4,698.14 |