- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,248.07 / $5,370.32
| Facility | | $4,265.80 | $5,248.07 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,466.84 / $5,248.07
| Professional | | $4,265.80 | $4,466.84 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,398.83 / $4,466.84
| Professional | | $1,905.46 | $2,398.83 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $4,466.84 / $12,589.25
| Facility | | $1,258.93 | $4,466.84 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $10,232.93
| Professional | | $5,248.07 | $5,248.07 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $5,888.44
| Professional | | $5,248.07 | $5,248.07 | $5,888.44 |