- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,660.83 / $4,416.20 / $8,110.75
| Facility | | $3,660.83 | $4,416.20 | $8,110.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.82 / $3,697.44 / $4,657.74
| Professional | | $3,660.82 | $3,697.44 | $4,657.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,660.83 / $5,926.88 / $11,287.25
| Facility | | $3,660.83 | $5,926.88 | $11,287.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,660.83 / $3,660.83
| Professional | | $3,660.83 | $3,660.83 | $3,660.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,453.62 / $3,660.83 / $3,660.83
| Facility | | $3,453.62 | $3,660.83 | $3,660.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,660.83 / $3,660.83
| Professional | | $3,660.83 | $3,660.83 | $3,660.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,660.83 / $4,026.91
| Professional | | $3,660.83 | $3,660.83 | $4,026.91 |