- 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
- $2,007.79 / $2,520.27 / $6,575.07
| Facility | | $2,007.79 | $2,520.27 | $6,575.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,108.41 / $5,210.57 / $5,210.57
| Professional | | $5,108.41 | $5,210.57 | $5,210.57 |
- 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
- $5,210.58 / $5,210.58 / $6,242.80
| Professional | | $5,210.58 | $5,210.58 | $6,242.80 |
- 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 / $7,407.19
| Professional | | $5,108.41 | $5,108.41 | $7,407.19 |