- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,686.85 / $7,055.43 / $13,254.40
| Facility | | $4,686.85 | $7,055.43 | $13,254.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,686.85 / $4,686.85 / $4,733.72
| Professional | | $4,686.85 | $4,686.85 | $4,733.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,421.56 / $4,962.46 / $6,422.01
| Facility | | $4,421.56 | $4,962.46 | $6,422.01 |
- 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
- $4,687.66 / $10,125.24 / $13,785.00
| Facility | | $4,687.66 | $10,125.24 | $13,785.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,672.47 / $4,672.47 / $4,856.33
| Professional | | $4,672.47 | $4,672.47 | $4,856.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,686.85 / $4,686.85 / $5,743.50
| Professional | | $4,686.85 | $4,686.85 | $5,743.50 |