- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,965.37 / $4,965.37 / $4,965.37
| Facility | | $4,965.37 | $4,965.37 | $4,965.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,904.07 / $4,965.37 / $5,087.97
| Professional | | $4,904.07 | $4,965.37 | $5,087.97 |
- 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
- $2,074.81 / $5,461.91 / $7,100.48
| Facility | | $2,074.81 | $5,461.91 | $7,100.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,108.41 / $5,108.41 / $6,376.51
| Professional | | $5,108.41 | $5,108.41 | $6,376.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,108.41 / $5,108.41 / $5,474.22
| Professional | | $5,108.41 | $5,108.41 | $5,474.22 |