- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,096.85 / $4,096.85 / $4,301.68
| Facility | | $4,096.85 | $4,096.85 | $4,301.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,855.86 / $4,000.45 / $4,096.85
| Professional | | $3,855.86 | $4,000.45 | $4,096.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,819.82 / $4,819.82 / $7,079.35
| Facility | | $4,819.82 | $4,819.82 | $7,079.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,819.82 / $4,819.82 / $5,229.05
| Professional | | $4,819.82 | $4,819.82 | $5,229.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,125.83 / $5,684.00 / $6,536.60
| Professional | | $5,125.83 | $5,684.00 | $6,536.60 |