- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,684.82 / $3,720.13 / $4,220.74
| Facility | | $3,684.82 | $3,720.13 | $4,220.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,134.89 / $3,720.13 / $5,437.70
| Professional | | $3,134.89 | $3,720.13 | $5,437.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,702.76 / $3,702.76 / $9,058.87
| Facility | | $3,702.76 | $3,702.76 | $9,058.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,702.76 / $3,906.15 / $6,626.30
| Professional | | $3,702.76 | $3,906.15 | $6,626.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,063.89 / $4,063.89 / $4,063.89
| Facility | | $4,063.89 | $4,063.89 | $4,063.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,454.31 / $3,454.31 / $4,185.81
| Professional | | $3,454.31 | $3,454.31 | $4,185.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,929.61 / $3,609.62 / $5,596.93
| Professional | | $2,929.61 | $3,609.62 | $5,596.93 |