- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,262.78 / $4,344.76 / $5,277.30
| Facility | | $4,262.78 | $4,344.76 | $5,277.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,673.47 / $4,332.10 / $6,222.49
| Professional | | $3,673.47 | $4,332.10 | $6,222.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,275.31 / $8,689.08 / $16,832.36
| Facility | | $8,275.31 | $8,689.08 | $16,832.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,852.45 / $6,450.00 / $8,003.21
| Professional | | $4,852.45 | $6,450.00 | $8,003.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,751.45 / $4,751.45 / $4,751.45
| Facility | | $4,751.45 | $4,751.45 | $4,751.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,038.73 / $4,751.45 / $4,893.99
| Professional | | $4,038.73 | $4,751.45 | $4,893.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,200.96 / $4,198.72 / $6,366.34
| Professional | | $3,200.96 | $4,198.72 | $6,366.34 |