- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $5,888.44 / $5,888.44
| Facility | | $1,621.81 | $5,888.44 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $5,128.61 / $5,888.44
| Professional | | $2,187.76 | $5,128.61 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Facility | | $5,370.32 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Professional | | $5,370.32 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,897.79 / $4,897.79
| Facility | | $4,677.35 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $4,897.79
| Professional | | $4,897.79 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $4,897.79
| Facility | | $4,897.79 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,897.79 / $4,897.79
| Professional | | $1,513.56 | $4,897.79 | $4,897.79 |