- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $6,456.54 / $12,022.64
| Facility | | $4,265.80 | $6,456.54 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $5,370.32
| Professional | | $4,265.80 | $4,265.80 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $5,623.41 / $11,748.98
| Facility | | $4,365.16 | $5,623.41 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $5,623.41
| Professional | | $4,265.80 | $4,265.80 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,265.80 / $6,025.60
| Facility | | $3,981.07 | $4,265.80 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $4,897.79
| Professional | | $4,265.80 | $4,265.80 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,265.80 / $6,606.93
| Facility | | $3,981.07 | $4,265.80 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,265.80 / $4,786.30
| Professional | | $3,981.07 | $4,265.80 | $4,786.30 |