- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,642.84 / $3,718.74 / $4,781.22
| Facility | | $3,642.84 | $3,718.74 | $4,781.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,209.83 / $3,644.55 / $4,983.89
| Professional | | $3,209.83 | $3,644.55 | $4,983.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,628.10 / $7,521.36 / $14,178.53
| Facility | | $6,628.10 | $7,521.36 | $14,178.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,937.69 / $3,971.24 / $5,462.36
| Professional | | $3,937.69 | $3,971.24 | $5,462.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,423.18 / $4,423.18 / $4,423.18
| Facility | | $4,423.18 | $4,423.18 | $4,423.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,228.92 / $4,328.12 / $4,555.88
| Professional | | $3,228.92 | $4,328.12 | $4,555.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,702.47 / $3,537.70 / $5,197.75
| Professional | | $2,702.47 | $3,537.70 | $5,197.75 |