- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,168.22 / $5,168.22 / $8,943.44
| Facility | | $5,168.22 | $5,168.22 | $8,943.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,168.22 / $5,168.22 / $6,011.98
| Professional | | $5,168.22 | $5,168.22 | $6,011.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,607.04 / $5,635.08 / $5,707.41
| Facility | | $5,607.04 | $5,635.08 | $5,707.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,765.97 / $5,626.66 / $5,677.13
| Professional | | $4,765.97 | $5,626.66 | $5,677.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,062.31 / $5,112.93 / $6,327.89
| Professional | | $5,062.31 | $5,112.93 | $6,327.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,593.57 / $4,968.58 / $8,446.59
| Facility | | $4,593.57 | $4,968.58 | $8,446.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,968.58 / $4,968.58 / $5,396.13
| Professional | | $4,968.58 | $4,968.58 | $5,396.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,393.00 / $5,168.22 / $5,612.96
| Professional | | $4,393.00 | $5,168.22 | $5,612.96 |