- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,877.91 / $5,201.43 / $8,114.25
| Facility | | $4,877.91 | $5,201.43 | $8,114.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,380.16 / $4,681.30 / $8,114.25
| Professional | | $4,380.16 | $4,681.30 | $8,114.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,839.48 / $3,839.48 / $3,839.48
| Facility | | $3,839.48 | $3,839.48 | $3,839.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,647.51 / $3,839.48 / $4,270.66
| Professional | | $3,647.51 | $3,839.48 | $4,270.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,672.84 / $6,672.84 / $8,341.04
| Professional | | $6,672.84 | $6,672.84 | $8,341.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,201.43 / $5,201.43 / $9,557.65
| Facility | | $5,201.43 | $5,201.43 | $9,557.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,256.19 / $5,256.19 / $6,570.24
| Professional | | $5,256.19 | $5,256.19 | $6,570.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,299.58 / $3,285.12 / $5,475.20
| Professional | | $2,299.58 | $3,285.12 | $5,475.20 |