- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,036.26 / $6,295.32 / $8,561.62
| Facility | | $5,036.26 | $6,295.32 | $8,561.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,036.26 / $5,036.26 / $6,610.09
| Professional | | $5,036.26 | $5,036.26 | $6,610.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,871.93 / $8,918.37 / $17,500.00
| Facility | | $4,871.93 | $8,918.37 | $17,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,721.49 / $4,721.49 / $6,295.32
| Professional | | $4,721.49 | $4,721.49 | $6,295.32 |
- 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
- $4,859.01 / $5,980.55 / $25,317.80
| Facility | | $4,859.01 | $5,980.55 | $25,317.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,459.18 / $5,246.10 / $6,033.02
| Professional | | $4,459.18 | $5,246.10 | $6,033.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,146.62 / $5,923.47 / $8,011.25
| Facility | | $5,146.62 | $5,923.47 | $8,011.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,459.18 / $5,246.10 / $6,169.41
| Professional | | $4,459.18 | $5,246.10 | $6,169.41 |