- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,128.02 / $4,950.66 / $8,601.77
| Facility | | $4,128.02 | $4,950.66 | $8,601.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,128.02 / $4,128.02 / $4,953.62
| Professional | | $4,128.02 | $4,128.02 | $4,953.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,128.02 / $6,593.69 / $13,081.70
| Facility | | $4,128.02 | $6,593.69 | $13,081.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,128.02 / $4,128.02 / $4,283.79
| Professional | | $4,128.02 | $4,128.02 | $4,283.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,894.36 / $4,128.02 / $4,128.02
| Facility | | $3,894.36 | $4,128.02 | $4,128.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,128.02 / $4,128.02 / $4,283.79
| Professional | | $4,128.02 | $4,128.02 | $4,283.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,128.02 / $4,128.02 / $4,776.12
| Professional | | $4,128.02 | $4,128.02 | $4,776.12 |