- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,351.02 / $5,514.70 / $11,822.60
| Facility | | $5,351.02 | $5,514.70 | $11,822.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,130.68 / $5,225.12 / $5,351.02
| Professional | | $5,130.68 | $5,225.12 | $5,351.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,871.93 / $7,975.12 / $16,211.50
| Facility | | $4,871.93 | $7,975.12 | $16,211.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,246.10 / $5,246.10 / $5,351.02
| Professional | | $5,246.10 | $5,246.10 | $5,351.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,351.02 / $5,351.02 / $5,351.02
| Facility | | $5,351.02 | $5,351.02 | $5,351.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,351.02 / $5,351.02 / $5,351.02
| Professional | | $5,351.02 | $5,351.02 | $5,351.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,855.30 / $5,923.47 / $8,011.25
| Facility | | $4,855.30 | $5,923.47 | $8,011.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,246.10 / $5,246.10 / $5,770.71
| Professional | | $5,246.10 | $5,246.10 | $5,770.71 |