- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $4,365.16
| Facility | | $4,365.16 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $4,365.16
| Professional | | $3,801.89 | $3,801.89 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,011.87 / $8,317.64
| Facility | | $4,073.80 | $5,011.87 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $3,801.89
| Professional | | $3,801.89 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $6,309.57 / $11,748.98
| Facility | | $5,011.87 | $6,309.57 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,890.45 / $3,890.45
| Professional | | $3,548.13 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,801.89 / $4,466.84
| Professional | | $3,467.37 | $3,801.89 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $4,168.69
| Professional | | $3,801.89 | $3,801.89 | $4,168.69 |