- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $5,888.44 / $9,120.11
| Facility | | $5,888.44 | $5,888.44 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $6,165.95 / $10,471.29
| Professional | | $4,570.88 | $6,165.95 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $8,128.31 / $8,128.31
| Facility | | $8,128.31 | $8,128.31 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,128.31 / $8,128.31 / $8,128.31
| Professional | | $8,128.31 | $8,128.31 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $8,128.31 / $8,128.31
| Facility | | $8,128.31 | $8,128.31 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $5,888.44 / $8,128.31
| Professional | | $5,888.44 | $5,888.44 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $8,511.38 / $14,454.40
| Facility | | $5,248.07 | $8,511.38 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,128.61 / $8,128.31
| Professional | | $3,467.37 | $5,128.61 | $8,128.31 |