- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,961.49 / $4,074.68 / $5,744.89
| Facility | | $3,961.49 | $4,074.68 | $5,744.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,122.66 / $4,122.66 / $4,122.66
| Professional | | $4,122.66 | $4,122.66 | $4,122.66 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $3,116.00 / $4,074.68 / $5,826.79
| Facility | | $3,116.00 | $4,074.68 | $5,826.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,506.04 / $3,772.85 / $4,199.97
| Professional | | $3,506.04 | $3,772.85 | $4,199.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,817.28 / $3,817.28 / $4,249.43
| Professional | | $3,817.28 | $3,817.28 | $4,249.43 |