- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,686.85 / $5,615.59 / $10,127.60
| Facility | | $4,686.85 | $5,615.59 | $10,127.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,686.85 / $4,733.72 / $5,663.03
| Professional | | $4,686.85 | $4,733.72 | $5,663.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,686.85 / $7,558.25 / $14,901.84
| Facility | | $4,686.85 | $7,558.25 | $14,901.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,686.85 / $4,686.85 / $4,686.85
| Professional | | $4,686.85 | $4,686.85 | $4,686.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,421.56 / $4,686.85 / $4,686.85
| Facility | | $4,421.56 | $4,686.85 | $4,686.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,686.85 / $4,686.85 / $4,686.85
| Professional | | $4,686.85 | $4,686.85 | $4,686.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,734.64 / $7,734.64 / $7,734.64
| Facility | | $7,734.64 | $7,734.64 | $7,734.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,686.85 / $4,686.85 / $5,882.00
| Professional | | $4,686.85 | $4,686.85 | $5,882.00 |