- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,008.14 / $4,527.42 / $4,580.72
| Facility | | $4,008.14 | $4,527.42 | $4,580.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,817.28 / $4,008.14 / $5,153.32
| Professional | | $3,817.28 | $4,008.14 | $5,153.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,624.00 / $2,624.00 / $2,886.40
| Facility | | $2,624.00 | $2,624.00 | $2,886.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,817.28 / $3,817.28 / $4,214.51
| Facility | | $3,817.28 | $3,817.28 | $4,214.51 |
- 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
- $17.00 / $17.00 / $20.00
| Professional | | $17.00 | $17.00 | $20.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,817.28 / $3,969.97 / $5,038.81
| Professional | | $3,817.28 | $3,969.97 | $5,038.81 |