- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,373.34 / $5,624.22 / $5,624.22
| Facility | | $5,373.34 | $5,624.22 | $5,624.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,686.85 / $5,606.96 / $5,624.22
| Professional | | $4,686.85 | $5,606.96 | $5,624.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,069.18 / $5,069.18 / $5,069.18
| Facility | | $5,069.18 | $5,069.18 | $5,069.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,864.55 / $5,069.18 / $5,069.18
| Professional | | $4,864.55 | $5,069.18 | $5,069.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,578.81 / $4,421.56 / $4,686.85
| Facility | | $2,578.81 | $4,421.56 | $4,686.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,686.85 / $4,686.85 / $4,686.85
| Professional | | $4,686.85 | $4,686.85 | $4,686.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,686.85 / $4,686.85 / $5,985.67
| Professional | | $4,686.85 | $4,686.85 | $5,985.67 |