- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $5,147.33 / $5,147.33
| Facility | | $1,400.00 | $5,147.33 | $5,147.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,147.33 / $5,389.56 / $6,043.42
| Professional | | $5,147.33 | $5,389.56 | $6,043.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,157.03 / $5,902.58 / $6,430.95
| Facility | | $5,157.03 | $5,902.58 | $6,430.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,716.40 / $5,716.40 / $5,716.40
| Professional | | $5,716.40 | $5,716.40 | $5,716.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.70 / $5,331.46 / $7,621.87
| Professional | | $3,388.70 | $5,331.46 | $7,621.87 |