- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,351.02 / $5,351.02 / $5,351.02
| Facility | | $5,351.02 | $5,351.02 | $5,351.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,225.12 / $5,225.12 / $5,351.02
| Professional | | $5,225.12 | $5,225.12 | $5,351.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,246.10 / $5,246.10 / $5,246.10
| Facility | | $5,246.10 | $5,246.10 | $5,246.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,246.10 / $5,246.10 / $5,246.10
| Professional | | $5,246.10 | $5,246.10 | $5,246.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,096.22 / $5,351.02 / $5,351.02
| Facility | | $5,096.22 | $5,351.02 | $5,351.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,351.02 / $5,351.02 / $5,351.02
| Professional | | $5,351.02 | $5,351.02 | $5,351.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,246.10 / $5,246.10 / $5,351.02
| Professional | | $5,246.10 | $5,246.10 | $5,351.02 |