- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,195.23 / $3,621.26 / $4,647.60
| Facility | | $3,195.23 | $3,621.26 | $4,647.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,052.69 / $2,052.69 / $2,052.69
| Professional | | $2,052.69 | $2,052.69 | $2,052.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,647.60 / $4,647.60 / $4,647.60
| Professional | | $4,647.60 | $4,647.60 | $4,647.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,256.00 / $4,801.71 / $5,311.63
| Professional | | $4,256.00 | $4,801.71 | $5,311.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,260.30 / $4,647.60 / $5,422.20
| Professional | | $4,260.30 | $4,647.60 | $5,422.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,873.00 / $4,647.60 / $5,809.50
| Professional | | $3,873.00 | $4,647.60 | $5,809.50 |