- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,810.58 / $5,281.99 / $11,546.10
| Facility | | $3,810.58 | $5,281.99 | $11,546.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,772.85 / $3,855.45 / $4,565.14
| Professional | | $3,772.85 | $3,855.45 | $4,565.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,214.00 / $2,597.76 / $3,856.64
| Facility | | $2,214.00 | $2,597.76 | $3,856.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,856.64 / $3,856.64 / $3,933.77
| Professional | | $3,856.64 | $3,856.64 | $3,933.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,601.20 / $3,601.20 / $3,817.28
| Facility | | $3,601.20 | $3,601.20 | $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
- $3,791.37 / $3,817.28 / $4,886.12
| Professional | | $3,791.37 | $3,817.28 | $4,886.12 |