- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,754.40 / $8,128.31
| Facility | | $3,890.45 | $5,754.40 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,890.45 / $3,890.45
| Professional | | $3,801.89 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,754.40 / $8,128.31
| Facility | | $3,890.45 | $5,754.40 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,890.45 / $3,981.07
| Professional | | $3,801.89 | $3,890.45 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $10,000.00 / $19,498.45
| Facility | | $5,011.87 | $10,000.00 | $19,498.45 |