- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $8,511.38 / $14,791.08
| Facility | | $5,128.61 | $8,511.38 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $7,244.36
| Professional | | $5,128.61 | $5,128.61 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $7,079.46 / $14,454.40
| Facility | | $5,370.32 | $7,079.46 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $6,760.83
| Professional | | $5,128.61 | $5,128.61 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $5,128.61 / $7,585.78
| Facility | | $4,897.79 | $5,128.61 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,370.32 / $6,760.83
| Professional | | $5,128.61 | $5,370.32 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,128.61 / $8,912.51
| Facility | | $5,011.87 | $5,128.61 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,128.61 / $5,754.40
| Professional | | $5,011.87 | $5,128.61 | $5,754.40 |