- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,991.31 / $4,393.00 / $4,393.00
| Facility | | $3,991.31 | $4,393.00 | $4,393.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.83 / $4,366.64 / $4,393.00
| Professional | | $3,660.83 | $4,366.64 | $4,393.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,947.82 / $3,947.82 / $3,947.82
| Facility | | $3,947.82 | $3,947.82 | $3,947.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,699.86 / $3,947.82 / $3,947.82
| Professional | | $3,699.86 | $3,947.82 | $3,947.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,905.31 / $3,660.83 / $3,660.83
| Facility | | $2,905.31 | $3,660.83 | $3,660.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,660.83 / $3,660.83
| Professional | | $3,660.83 | $3,660.83 | $3,660.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,660.83 / $3,919.73
| Professional | | $3,660.83 | $3,660.83 | $3,919.73 |