- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,968.58 / $5,366.07 / $9,122.32
| Facility | | $4,968.58 | $5,366.07 | $9,122.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,581.69 / $5,581.69 / $5,581.69
| Professional | | $5,581.69 | $5,581.69 | $5,581.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,617.15 / $4,128.02 / $6,546.32
| Facility | | $2,617.15 | $4,128.02 | $6,546.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,875.68 / $4,875.68 / $5,168.22
| Facility | | $4,875.68 | $4,875.68 | $5,168.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $513.60 / $5,168.22 / $5,168.22
| Professional | | $513.60 | $5,168.22 | $5,168.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,780.19 / $4,968.58 / $7,673.48
| Facility | | $3,780.19 | $4,968.58 | $7,673.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,968.58 / $4,968.58 / $5,168.22
| Professional | | $4,968.58 | $4,968.58 | $5,168.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,168.22 / $5,168.22 / $5,538.33
| Professional | | $5,168.22 | $5,168.22 | $5,538.33 |