- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,036.26 / $5,036.26 / $9,631.84
| Facility | | $5,036.26 | $5,036.26 | $9,631.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,036.26 / $6,295.32 / $6,295.32
| Professional | | $5,036.26 | $6,295.32 | $6,295.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,508.41 / $5,535.95 / $5,607.01
| Facility | | $5,508.41 | $5,535.95 | $5,607.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,682.14 / $5,527.69 / $5,607.01
| Professional | | $4,682.14 | $5,527.69 | $5,607.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,718.88 / $3,756.06 / $4,722.97
| Professional | | $3,718.88 | $3,756.06 | $4,722.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,036.26 / $5,036.26 / $15,108.78
| Facility | | $5,036.26 | $5,036.26 | $15,108.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,246.10 / $5,246.10 / $5,697.53
| Professional | | $5,246.10 | $5,246.10 | $5,697.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,459.18 / $5,246.10 / $5,697.53
| Professional | | $4,459.18 | $5,246.10 | $5,697.53 |