- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,275.21 / $5,275.21 / $7,385.29
| Facility | | $5,275.21 | $5,275.21 | $7,385.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,275.21 / $5,275.21 / $5,275.21
| Professional | | $5,275.21 | $5,275.21 | $5,275.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $612.26 / $1,123.08 / $4,747.68
| Facility | | $612.26 | $1,123.08 | $4,747.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,747.68 / $4,747.68 / $4,842.64
| Professional | | $4,747.68 | $4,747.68 | $4,842.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,483.93 / $4,483.93 / $4,483.93
| Facility | | $4,483.93 | $4,483.93 | $4,483.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,483.93 / $4,483.93 / $4,483.93
| Professional | | $4,483.93 | $4,483.93 | $4,483.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,275.21 / $5,275.21 / $6,066.49
| Professional | | $5,275.21 | $5,275.21 | $6,066.49 |