- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,130.09 / $6,130.09 / $6,130.09
| Facility | | $6,130.09 | $6,130.09 | $6,130.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,130.09 / $6,130.09 / $6,130.09
| Professional | | $6,130.09 | $6,130.09 | $6,130.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,758.80 / $4,010.87 / $8,275.62
| Facility | | $2,758.80 | $4,010.87 | $8,275.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,275.62 / $8,275.62 / $8,441.14
| Professional | | $8,275.62 | $8,275.62 | $8,441.14 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $5,108.41 / $5,108.41 / $6,385.51
| Professional | | $5,108.41 | $5,108.41 | $6,385.51 |