- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $5,888.44
| Facility | | $4,897.79 | $4,897.79 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,011.87 / $10,232.93
| Professional | | $3,981.07 | $5,011.87 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,888.44 / $5,888.44
| Facility | | $3,981.07 | $5,888.44 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $9,549.93 / $14,125.38
| Professional | | $3,981.07 | $9,549.93 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,495.41 / $7,762.47
| Professional | | $3,981.07 | $5,495.41 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $5,888.44 / $14,454.40
| Facility | | $4,897.79 | $5,888.44 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,623.41 / $8,317.64
| Professional | | $4,265.80 | $5,623.41 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $6,309.57 / $7,244.36
| Professional | | $4,677.35 | $6,309.57 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,890.45 / $6,025.60
| Facility | | $1,698.24 | $3,890.45 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,623.41 / $7,943.28
| Professional | | $4,786.30 | $5,623.41 | $7,943.28 |