- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,692.14 / $3,729.06 / $3,774.77
| Facility | | $3,692.14 | $3,729.06 | $3,774.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,692.14 / $3,692.14 / $3,876.75
| Professional | | $3,692.14 | $3,692.14 | $3,876.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,678.89 / $3,692.14 / $7,125.83
| Facility | | $3,678.89 | $3,692.14 | $7,125.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,692.14 / $3,692.14 / $3,765.98
| Professional | | $3,692.14 | $3,692.14 | $3,765.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,483.15 / $3,692.14 / $3,692.14
| Facility | | $3,483.15 | $3,692.14 | $3,692.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,692.14 / $3,692.14 / $3,692.14
| Professional | | $3,692.14 | $3,692.14 | $3,692.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,421.37 / $3,556.75 / $3,692.14
| Facility | | $3,421.37 | $3,556.75 | $3,692.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,692.14 / $3,692.14 / $4,061.35
| Professional | | $3,692.14 | $3,692.14 | $4,061.35 |