- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,351.02 / $8,036.70 / $17,592.30
| Facility | | $5,351.02 | $8,036.70 | $17,592.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,351.02 / $5,351.02 / $5,351.02
| Professional | | $5,351.02 | $5,351.02 | $5,351.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,016.64 / $7,975.12 / $16,211.50
| Facility | | $5,016.64 | $7,975.12 | $16,211.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,246.10 / $5,246.10 / $5,351.02
| Professional | | $5,246.10 | $5,246.10 | $5,351.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,351.02 / $5,351.02 / $5,351.02
| Facility | | $5,351.02 | $5,351.02 | $5,351.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,351.02 / $5,351.02 / $5,351.02
| Professional | | $5,351.02 | $5,351.02 | $5,351.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,351.02 / $5,351.02 / $5,351.02
| Professional | | $5,351.02 | $5,351.02 | $5,351.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,721.49 / $5,246.10 / $5,823.17
| Professional | | $4,721.49 | $5,246.10 | $5,823.17 |