- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,351.02 / $7,544.94 / $13,056.50
| Facility | | $5,351.02 | $7,544.94 | $13,056.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,343.77 / $5,225.12 / $5,351.02
| Professional | | $4,343.77 | $5,225.12 | $5,351.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,351.02 / $6,295.32 / $6,924.85
| Facility | | $5,351.02 | $6,295.32 | $6,924.85 |
- 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
- $8,702.00 / $11,435.42 / $13,785.00
| Facility | | $8,702.00 | $11,435.42 | $13,785.00 |
- 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
- $4,252.04 / $5,146.62 / $12,866.55
| Facility | | $4,252.04 | $5,146.62 | $12,866.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,246.10 / $5,246.10 / $6,295.32
| Professional | | $5,246.10 | $5,246.10 | $6,295.32 |