- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,051.95 / $5,051.95 / $6,668.57
| Facility | | $5,051.95 | $5,051.95 | $6,668.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,051.95 / $5,051.95 / $5,051.95
| Professional | | $5,051.95 | $5,051.95 | $5,051.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,546.76 / $4,546.76 / $6,820.14
| Facility | | $4,546.76 | $4,546.76 | $6,820.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,546.76 / $4,546.76 / $4,637.70
| Professional | | $4,546.76 | $4,546.76 | $4,637.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,294.16 / $4,294.16 / $4,294.16
| Facility | | $4,294.16 | $4,294.16 | $4,294.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,294.16 / $4,294.16 / $4,294.16
| Professional | | $4,294.16 | $4,294.16 | $4,294.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,209.96 / $4,209.96 / $5,051.95
| Professional | | $4,209.96 | $4,209.96 | $5,051.95 |