- 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
- $5,351.02 / $5,351.02 / $6,849.31
| Professional | | $5,351.02 | $5,351.02 | $6,849.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,036.26 / $5,036.26 / $5,036.26
| Professional | | $5,036.26 | $5,036.26 | $5,036.26 |
- 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 / $6,295.32
| Professional | | $5,246.10 | $5,246.10 | $6,295.32 |