- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $6,165.95 / $8,128.31
| Facility | | $5,128.61 | $6,165.95 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,011.87 / $5,128.61
| Professional | | $4,786.30 | $5,011.87 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $7,943.28 / $12,882.50
| Facility | | $5,623.41 | $7,943.28 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,128.61 / $5,128.61
| Professional | | $5,011.87 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Facility | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,011.87 / $5,248.07
| Professional | | $4,466.84 | $5,011.87 | $5,248.07 |