- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,564.80 / $6,201.87 / $6,201.87
| Facility | | $5,564.80 | $6,201.87 | $6,201.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,168.22 / $5,962.30 / $6,201.87
| Professional | | $5,168.22 | $5,962.30 | $6,201.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,390.44 / $5,390.44 / $5,390.44
| Facility | | $5,390.44 | $5,390.44 | $5,390.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,156.07 / $5,390.44 / $5,390.44
| Professional | | $5,156.07 | $5,390.44 | $5,390.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $716.46 / $4,875.68 / $5,168.22
| Facility | | $716.46 | $4,875.68 | $5,168.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,168.22 / $5,168.22 / $5,168.22
| Professional | | $5,168.22 | $5,168.22 | $5,168.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,909.82 / $5,168.22 / $5,168.22
| Professional | | $4,909.82 | $5,168.22 | $5,168.22 |