- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $5,495.41 / $9,549.93
| Facility | | $4,570.88 | $5,495.41 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $5,495.41 / $9,120.11
| Professional | | $4,570.88 | $5,495.41 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,888.44 / $19,952.62
| Facility | | $4,265.80 | $5,888.44 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $6,606.93 / $12,589.25
| Professional | | $5,623.41 | $6,606.93 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $40,738.03
| Facility | | $7,585.78 | $7,585.78 | $40,738.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $15,488.17
| Professional | | $5,495.41 | $5,495.41 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $7,079.46 / $12,882.50
| Facility | | $4,265.80 | $7,079.46 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,370.32 / $7,943.28
| Professional | | $3,890.45 | $5,370.32 | $7,943.28 |