- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,672.47 / $4,686.85 / $4,686.85
| Facility | | $4,672.47 | $4,686.85 | $4,686.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,686.85 / $4,686.85 / $8,036.78
| Professional | | $4,686.85 | $4,686.85 | $8,036.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,048.61 / $3,699.63 / $4,977.18
| Facility | | $3,048.61 | $3,699.63 | $4,977.18 |
- 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
- $4,686.85 / $4,686.85 / $4,686.85
| Facility | | $4,686.85 | $4,686.85 | $4,686.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,686.85 / $4,686.85 / $6,383.32
| Professional | | $4,686.85 | $4,686.85 | $6,383.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.57 / $4,686.85 / $4,686.85
| Professional | | $4,466.57 | $4,686.85 | $4,686.85 |