- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,495.46 / $3,569.49 / $4,589.03
| Facility | | $3,495.46 | $3,569.49 | $4,589.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,824.92 / $3,666.74 / $5,171.78
| Professional | | $2,824.92 | $3,666.74 | $5,171.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,152.41 / $8,041.35 / $13,304.78
| Facility | | $6,152.41 | $8,041.35 | $13,304.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,670.43 / $3,670.43 / $5,821.91
| Professional | | $3,670.43 | $3,670.43 | $5,821.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,728.96 / $4,728.96 / $4,728.96
| Facility | | $4,728.96 | $4,728.96 | $4,728.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,452.14 / $4,728.96 / $4,870.83
| Professional | | $3,452.14 | $4,728.96 | $4,870.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,926.06 / $8,148.31 / $8,148.31
| Facility | | $6,926.06 | $8,148.31 | $8,148.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,540.69 / $3,494.80 / $4,884.54
| Professional | | $2,540.69 | $3,494.80 | $4,884.54 |