- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,199.72 / $3,626.35 / $4,654.14
| Facility | | $3,199.72 | $3,626.35 | $4,654.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,055.58 / $2,055.58 / $2,055.58
| Professional | | $2,055.58 | $2,055.58 | $2,055.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,654.14 / $4,654.14 / $4,654.14
| Professional | | $4,654.14 | $4,654.14 | $4,654.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,655.08 / $4,382.64 / $4,848.06
| Professional | | $3,655.08 | $4,382.64 | $4,848.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,266.30 / $4,654.14 / $5,429.83
| Professional | | $4,266.30 | $4,654.14 | $5,429.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,878.45 / $4,654.14 / $5,817.68
| Professional | | $3,878.45 | $4,654.14 | $5,817.68 |