- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,162.16 / $7,554.38 / $7,554.38
| Facility | | $5,162.16 | $7,554.38 | $7,554.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,162.16 / $5,351.02 / $7,554.38
| Professional | | $5,162.16 | $5,351.02 | $7,554.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,924.54 / $3,924.54 / $4,316.99
| Facility | | $3,924.54 | $3,924.54 | $4,316.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,090.63 / $5,351.02 / $5,351.02
| Facility | | $4,090.63 | $5,351.02 | $5,351.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,351.02 / $5,351.02 / $5,351.02
| Professional | | $5,351.02 | $5,351.02 | $5,351.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,299.81 / $4,369.77 / $4,855.30
| Professional | | $4,299.81 | $4,369.77 | $4,855.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,146.62 / $5,146.62 / $5,146.62
| Facility | | $5,146.62 | $5,146.62 | $5,146.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,036.26 / $5,246.10 / $6,715.01
| Professional | | $5,036.26 | $5,246.10 | $6,715.01 |