- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,193.10 / $4,294.16 / $5,304.55
| Facility | | $4,193.10 | $4,294.16 | $5,304.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,041.56 / $4,193.12 / $4,294.16
| Professional | | $4,041.56 | $4,193.12 | $4,294.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,067.49 / $3,704.75 / $7,577.93
| Facility | | $1,067.49 | $3,704.75 | $7,577.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,782.67 / $4,209.96 / $4,294.16
| Professional | | $3,782.67 | $4,209.96 | $4,294.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,294.16 / $4,294.16 / $4,294.16
| Facility | | $4,294.16 | $4,294.16 | $4,294.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,294.16 / $4,294.16 / $4,294.16
| Professional | | $4,294.16 | $4,294.16 | $4,294.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,209.96 / $4,209.96 / $5,051.95
| Professional | | $4,209.96 | $4,209.96 | $5,051.95 |