- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $8,317.64 / $14,791.08
| Facility | | $5,128.61 | $8,317.64 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $5,754.40
| Professional | | $4,897.79 | $4,897.79 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $7,585.78 / $11,748.98
| Facility | | $5,495.41 | $7,585.78 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $4,897.79
| Professional | | $4,897.79 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $4,897.79
| Facility | | $4,897.79 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $4,897.79
| Professional | | $4,897.79 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $5,128.61 / $6,165.95
| Professional | | $1,348.96 | $5,128.61 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $4,897.79 / $5,128.61
| Professional | | $1,445.44 | $4,897.79 | $5,128.61 |