- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $6,025.60 / $19,498.45
| Facility | | $5,128.61 | $6,025.60 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,370.32 / $8,317.64
| Professional | | $5,128.61 | $5,370.32 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,370.32 / $14,454.40
| Facility | | $5,128.61 | $5,370.32 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $6,025.60
| Professional | | $5,128.61 | $5,128.61 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $5,128.61 / $5,128.61
| Facility | | $4,897.79 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,370.32
| Professional | | $5,128.61 | $5,128.61 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,623.41 / $25,118.86
| Facility | | $5,011.87 | $5,623.41 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,011.87 / $5,754.40
| Professional | | $4,265.80 | $5,011.87 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $6,025.60 / $6,606.93
| Facility | | $5,128.61 | $6,025.60 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,128.61 / $5,888.44
| Professional | | $4,677.35 | $5,128.61 | $5,888.44 |