- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,193.12 / $4,294.16 / $5,051.95
| Facility | | $4,193.12 | $4,294.16 | $5,051.95 |
- 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
- $4,736.21 / $7,051.68 / $13,016.78
| Facility | | $4,736.21 | $7,051.68 | $13,016.78 |
- 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 |