- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,210.57 / $5,210.58 / $16,241.68
| Facility | | $5,210.57 | $5,210.58 | $16,241.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,904.07 / $5,087.97 / $5,210.58
| Professional | | $4,904.07 | $5,087.97 | $5,210.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,594.85 / $5,210.58 / $5,946.29
| Facility | | $4,594.85 | $5,210.58 | $5,946.29 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $3,570.75 / $4,496.10 / $9,373.99
| Facility | | $3,570.75 | $4,496.10 | $9,373.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,892.29 / $7,815.87 / $7,815.87
| Professional | | $6,892.29 | $7,815.87 | $7,815.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,108.41 / $5,108.41 / $5,414.91
| Professional | | $5,108.41 | $5,108.41 | $5,414.91 |