- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,878.43 / $5,202.01 / $8,115.13
| Facility | | $4,878.43 | $5,202.01 | $8,115.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,380.64 / $4,654.43 / $6,502.51
| Professional | | $4,380.64 | $4,654.43 | $6,502.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,839.90 / $3,839.90 / $3,839.90
| Facility | | $3,839.90 | $3,839.90 | $3,839.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,647.90 / $3,839.90 / $4,271.12
| Professional | | $3,647.90 | $3,839.90 | $4,271.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,673.67 / $6,673.67 / $8,342.09
| Professional | | $6,673.67 | $6,673.67 | $8,342.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,202.01 / $5,202.01 / $9,558.69
| Facility | | $5,202.01 | $5,202.01 | $9,558.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,202.01 / $5,256.77 / $6,570.96
| Professional | | $5,202.01 | $5,256.77 | $6,570.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,299.84 / $3,285.48 / $5,475.80
| Professional | | $2,299.84 | $3,285.48 | $5,475.80 |