- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,157.30 / $5,262.19 / $8,003.18
| Facility | | $5,157.30 | $5,262.19 | $8,003.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,387.64 / $5,206.75 / $7,610.71
| Professional | | $4,387.64 | $5,206.75 | $7,610.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,857.64 / $4,857.64 / $11,126.45
| Facility | | $4,857.64 | $4,857.64 | $11,126.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,857.64 / $4,857.64 / $8,545.76
| Professional | | $4,857.64 | $4,857.64 | $8,545.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,687.89 / $5,687.89 / $5,687.89
| Facility | | $5,687.89 | $5,687.89 | $5,687.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,834.71 / $5,687.89 / $5,858.53
| Professional | | $4,834.71 | $5,687.89 | $5,858.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,784.36 / $5,152.31 / $7,726.90
| Professional | | $3,784.36 | $5,152.31 | $7,726.90 |