- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,527.42 / $4,580.72 / $4,753.79
| Facility | | $4,527.42 | $4,580.72 | $4,753.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,817.28 / $3,817.28 / $4,580.72
| Professional | | $3,817.28 | $3,817.28 | $4,580.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,093.18 / $4,093.18 / $4,093.18
| Facility | | $4,093.18 | $4,093.18 | $4,093.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,638.34 / $4,093.18 / $4,093.18
| Professional | | $3,638.34 | $4,093.18 | $4,093.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,929.14 / $3,817.28 / $3,817.28
| Facility | | $2,929.14 | $3,817.28 | $3,817.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,817.28 / $3,817.28 / $3,817.28
| Professional | | $3,817.28 | $3,817.28 | $3,817.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,817.28 / $4,046.32 / $4,886.12
| Professional | | $3,817.28 | $4,046.32 | $4,886.12 |