- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,210.58 / $5,210.58 / $6,299.62
| Facility | | $5,210.58 | $5,210.58 | $6,299.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,904.07 / $5,210.58 / $5,271.88
| Professional | | $4,904.07 | $5,210.58 | $5,271.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,210.58 / $5,210.58 / $5,210.58
| Facility | | $5,210.58 | $5,210.58 | $5,210.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,210.58 / $5,210.58 / $5,210.58
| Professional | | $5,210.58 | $5,210.58 | $5,210.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,655.39 / $5,271.88 / $7,538.79
| Facility | | $3,655.39 | $5,271.88 | $7,538.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $4,455.05 / $11,356.00
| Professional | | $30.00 | $4,455.05 | $11,356.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,823.59 / $6,988.31 / $7,279.49
| Professional | | $5,823.59 | $6,988.31 | $7,279.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,108.41 / $5,108.41 / $7,151.77
| Professional | | $5,108.41 | $5,108.41 | $7,151.77 |