- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,660.83 / $5,458.29 / $8,296.60
| Facility | | $3,660.83 | $5,458.29 | $8,296.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,638.86 / $3,660.83 / $4,026.92
| Professional | | $3,638.86 | $3,660.83 | $4,026.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,453.62 / $3,660.83 / $3,727.55
| Facility | | $3,453.62 | $3,660.83 | $3,727.55 |
- 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
- $3,660.83 / $3,660.83 / $3,660.83
| Facility | | $3,660.83 | $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 / $4,058.08
| Professional | | $3,660.83 | $3,660.83 | $4,058.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,638.86 / $3,638.86 / $3,660.83
| Professional | | $3,638.86 | $3,638.86 | $3,660.83 |