- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $9,332.54 / $12,302.69
| Facility | | $5,128.61 | $9,332.54 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $6,165.95
| Professional | | $5,128.61 | $5,128.61 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $5,128.61 / $5,370.32
| Facility | | $4,897.79 | $5,128.61 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,623.41
| Professional | | $5,128.61 | $5,128.61 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $5,128.61 / $5,128.61
| Facility | | $630.96 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,495.41 / $5,495.41
| Professional | | $5,128.61 | $5,495.41 | $5,495.41 |
- 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 / $5,370.32
| Professional | | $5,011.87 | $5,128.61 | $5,370.32 |
- 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 |