- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,665.16 / $4,755.85 / $5,701.34
| Facility | | $4,665.16 | $4,755.85 | $5,701.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,899.69 / $4,767.60 / $6,722.47
| Professional | | $3,899.69 | $4,767.60 | $6,722.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,059.76 / $9,387.26 / $17,726.80
| Facility | | $8,059.76 | $9,387.26 | $17,726.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,879.76 / $4,923.92 / $7,233.04
| Professional | | $4,879.76 | $4,923.92 | $7,233.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,300.68 / $6,300.68 / $6,300.68
| Facility | | $6,300.68 | $6,300.68 | $6,300.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,599.50 / $6,165.28 / $6,489.70
| Professional | | $4,599.50 | $6,165.28 | $6,489.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,398.09 / $4,490.03 / $6,441.28
| Professional | | $3,398.09 | $4,490.03 | $6,441.28 |