- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $5,370.32
| Facility | | $3,467.37 | $3,467.37 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,548.13 / $6,165.95
| Professional | | $2,691.53 | $3,548.13 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Facility | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Professional | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $4,677.35
| Facility | | $4,677.35 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $4,677.35
| Professional | | $3,467.37 | $3,467.37 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,897.79 / $8,317.64
| Facility | | $4,073.80 | $4,897.79 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,019.95 / $4,677.35
| Professional | | $2,041.74 | $3,019.95 | $4,677.35 |