- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,686.85 / $7,877.78 / $10,653.20
| Facility | | $4,686.85 | $7,877.78 | $10,653.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,672.47 / $4,686.85 / $5,155.54
| Professional | | $4,672.47 | $4,686.85 | $5,155.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,421.56 / $4,686.85 / $4,890.46
| Facility | | $4,421.56 | $4,686.85 | $4,890.46 |
- 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
- $1,842.06 / $4,686.85 / $4,686.85
| Facility | | $1,842.06 | $4,686.85 | $4,686.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,686.85 / $4,952.14 / $4,952.14
| Professional | | $4,686.85 | $4,952.14 | $4,952.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,686.85 / $4,686.85 / $6,196.93
| Professional | | $4,686.85 | $4,686.85 | $6,196.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,672.47 / $4,672.47 / $4,686.85
| Professional | | $4,672.47 | $4,672.47 | $4,686.85 |