- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,971.34 / $4,971.34 / $4,971.34
| Facility | | $4,971.34 | $4,971.34 | $4,971.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,678.89 / $4,854.35 / $4,971.34
| Professional | | $4,678.89 | $4,854.35 | $4,971.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,177.85 / $6,283.58 / $8,453.43
| Facility | | $5,177.85 | $6,283.58 | $8,453.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,873.85 / $4,873.85 / $4,873.85
| Professional | | $4,873.85 | $4,873.85 | $4,873.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,971.34 / $4,971.34 / $4,971.34
| Facility | | $4,971.34 | $4,971.34 | $4,971.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,971.34 / $4,971.34 / $5,579.59
| Professional | | $4,971.34 | $4,971.34 | $5,579.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,142.78 / $4,873.85 / $5,361.25
| Professional | | $4,142.78 | $4,873.85 | $5,361.25 |