- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,489.52 / $3,567.75 / $4,675.47
| Facility | | $3,489.52 | $3,567.75 | $4,675.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,773.54 / $3,667.43 / $5,211.68
| Professional | | $2,773.54 | $3,667.43 | $5,211.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,199.89 / $8,017.45 / $13,687.49
| Facility | | $6,199.89 | $8,017.45 | $13,687.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,753.85 / $3,772.23 / $5,931.58
| Professional | | $3,753.85 | $3,772.23 | $5,931.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,865.01 / $4,865.01 / $4,865.01
| Facility | | $4,865.01 | $4,865.01 | $4,865.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,551.46 / $4,865.01 / $5,010.96
| Professional | | $3,551.46 | $4,865.01 | $5,010.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,320.94 / $5,320.94 / $5,320.94
| Facility | | $5,320.94 | $5,320.94 | $5,320.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,733.48 / $3,525.31 / $4,898.78
| Professional | | $2,733.48 | $3,525.31 | $4,898.78 |