- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,099.21 / $5,099.21 / $10,147.40
| Facility | | $5,099.21 | $5,099.21 | $10,147.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,099.21 / $5,099.21 / $5,099.21
| Professional | | $5,099.21 | $5,099.21 | $5,099.21 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $4,859.01 / $5,305.50 / $7,291.87
| Facility | | $4,859.01 | $5,305.50 | $7,291.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,246.10 / $5,246.10 / $5,246.10
| Professional | | $5,246.10 | $5,246.10 | $5,246.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,011.25 / $8,011.25 / $8,011.25
| Facility | | $8,011.25 | $8,011.25 | $8,011.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,246.10 / $5,246.10 / $5,246.10
| Professional | | $5,246.10 | $5,246.10 | $5,246.10 |