- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,410.56 / $8,410.56 / $9,063.10
| Facility | | $8,410.56 | $8,410.56 | $9,063.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,081.45 / $3,081.45
| Professional | | $3,081.45 | $3,081.45 | $3,081.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,227.56 / $2,844.16 / $7,294.75
| Facility | | $2,227.56 | $2,844.16 | $7,294.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,081.45 / $3,081.45
| Professional | | $3,081.45 | $3,081.45 | $3,081.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,081.45 / $3,081.45
| Facility | | $3,081.45 | $3,081.45 | $3,081.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,081.45 / $3,081.45
| Professional | | $3,081.45 | $3,081.45 | $3,081.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,301.91 / $2,301.91 / $2,787.61
| Professional | | $2,301.91 | $2,301.91 | $2,787.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,410.56 / $8,410.56 / $9,063.10
| Facility | | $8,410.56 | $8,410.56 | $9,063.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,081.45 / $9,063.10
| Professional | | $3,081.45 | $3,081.45 | $9,063.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,301.91 / $3,021.04 / $4,380.51
| Professional | | $2,301.91 | $3,021.04 | $4,380.51 |