- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $8,912.51
| Facility | | $5,495.41 | $5,495.41 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,801.89 / $5,370.32
| Professional | | $2,884.03 | $3,801.89 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,630.27 / $3,548.13
| Professional | | $1,698.24 | $2,630.27 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,302.69 / $12,302.69 / $12,302.69
| Facility | | $12,302.69 | $12,302.69 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $6,606.93
| Professional | | $5,495.41 | $5,495.41 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $5,495.41
| Facility | | $5,495.41 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,265.80 / $5,370.32
| Professional | | $2,951.21 | $4,265.80 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,495.41 / $7,943.28
| Professional | | $3,311.31 | $5,495.41 | $7,943.28 |