- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,420.06 / $5,436.75 / $5,436.75
| Facility | | $5,420.06 | $5,436.75 | $5,436.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,436.75 / $5,436.75 / $5,436.75
| Professional | | $5,436.75 | $5,436.75 | $5,436.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,448.49 / $6,545.48 / $7,074.24
| Facility | | $5,448.49 | $6,545.48 | $7,074.24 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $6,688.58 / $9,254.06 / $13,285.54
| Facility | | $6,688.58 | $9,254.06 | $13,285.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,452.51 / $4,686.85 / $4,686.85
| Professional | | $4,452.51 | $4,686.85 | $4,686.85 |