- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,376.27 / $3,631.08 / $4,160.12
| Facility | | $3,376.27 | $3,631.08 | $4,160.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,376.27 / $4,048.86 / $5,885.96
| Professional | | $3,376.27 | $4,048.86 | $5,885.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,391.66 / $4,391.66 / $4,391.66
| Facility | | $4,391.66 | $4,391.66 | $4,391.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,732.91 / $3,732.91 / $4,391.66
| Professional | | $3,732.91 | $3,732.91 | $4,391.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,565.82 / $5,284.02 / $7,908.16
| Professional | | $3,565.82 | $5,284.02 | $7,908.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,326.52 / $6,326.52 / $6,326.52
| Professional | | $6,326.52 | $6,326.52 | $6,326.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,396.02 / $3,945.29 / $5,282.94
| Professional | | $3,396.02 | $3,945.29 | $5,282.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,300.34 / $4,300.34 / $7,908.16
| Professional | | $4,300.34 | $4,300.34 | $7,908.16 |