- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,855.86 / $3,855.86 / $8,675.68
| Facility | | $3,855.86 | $3,855.86 | $8,675.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,855.86 / $4,000.45 / $4,819.82
| Professional | | $3,855.86 | $4,000.45 | $4,819.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,819.82 / $5,001.75 / $6,352.22
| Professional | | $4,819.82 | $5,001.75 | $6,352.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,855.86 / $4,096.85 / $4,859.25
| Facility | | $3,855.86 | $4,096.85 | $4,859.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,684.00 / $6,327.49 / $7,086.79
| Professional | | $5,684.00 | $6,327.49 | $7,086.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,684.00 / $6,327.49 / $7,086.79
| Professional | | $5,684.00 | $6,327.49 | $7,086.79 |