- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,654.64 / $4,963.37 / $7,742.86
| Facility | | $4,654.64 | $4,963.37 | $7,742.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,179.68 / $4,440.91 / $6,204.21
| Professional | | $4,179.68 | $4,440.91 | $6,204.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,663.75 / $3,663.75 / $3,663.75
| Facility | | $3,663.75 | $3,663.75 | $3,663.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,480.56 / $3,663.75 / $4,075.19
| Professional | | $3,480.56 | $3,663.75 | $4,075.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,367.63 / $6,367.63 / $7,959.54
| Professional | | $6,367.63 | $6,367.63 | $7,959.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,963.37 / $4,963.37 / $9,120.19
| Facility | | $4,963.37 | $4,963.37 | $9,120.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,015.62 / $5,015.62 / $6,269.52
| Professional | | $5,015.62 | $5,015.62 | $6,269.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,194.33 / $4,702.14 / $6,269.52
| Facility | | $2,194.33 | $4,702.14 | $6,269.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,194.33 / $3,134.76 / $5,224.60
| Professional | | $2,194.33 | $3,134.76 | $5,224.60 |