- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,074.81 / $4,235.89 / $5,210.58
| Facility | | $2,074.81 | $4,235.89 | $5,210.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,210.58 / $5,210.58 / $5,210.58
| Professional | | $5,210.58 | $5,210.58 | $5,210.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,147.42 / $8,051.88 / $17,656.71
| Facility | | $2,147.42 | $8,051.88 | $17,656.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,108.41 / $5,108.41 / $5,108.41
| Professional | | $5,108.41 | $5,108.41 | $5,108.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,210.58 / $5,210.58 / $5,210.58
| Facility | | $5,210.58 | $5,210.58 | $5,210.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,210.58 / $5,210.58 / $5,210.58
| Professional | | $5,210.58 | $5,210.58 | $5,210.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,815.87 / $7,815.87 / $7,815.87
| Professional | | $7,815.87 | $7,815.87 | $7,815.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,858.10 / $5,108.41 / $5,639.68
| Professional | | $4,858.10 | $5,108.41 | $5,639.68 |