- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $5,495.41
| Facility | | $5,495.41 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $5,495.41
| Professional | | $4,786.30 | $4,786.30 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $6,760.83 / $7,079.46
| Facility | | $5,495.41 | $6,760.83 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Professional | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $8,317.64 / $16,595.87
| Facility | | $6,606.93 | $8,317.64 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,011.87 / $5,011.87
| Professional | | $4,786.30 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,677.35 / $5,754.40
| Professional | | $4,265.80 | $4,677.35 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Professional | | $4,786.30 | $4,786.30 | $4,786.30 |