- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,812.74 / $4,868.43 / $5,775.28
| Facility | | $4,812.74 | $4,868.43 | $5,775.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,850.82 / $4,868.43 / $6,623.41
| Professional | | $3,850.82 | $4,868.43 | $6,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,141.76 / $9,462.42 / $18,405.21
| Facility | | $8,141.76 | $9,462.42 | $18,405.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,871.02 / $4,893.57 / $7,290.96
| Professional | | $4,871.02 | $4,893.57 | $7,290.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,541.83 / $6,541.83 / $6,541.83
| Facility | | $6,541.83 | $6,541.83 | $6,541.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,775.54 / $6,401.26 / $6,738.08
| Professional | | $4,775.54 | $6,401.26 | $6,738.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,078.09 / $10,680.11 / $10,680.11
| Facility | | $9,078.09 | $10,680.11 | $10,680.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,330.12 / $4,574.47 / $6,538.76
| Professional | | $3,330.12 | $4,574.47 | $6,538.76 |