- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,106.14 / $5,106.14 / $5,106.14
| Facility | | $5,106.14 | $5,106.14 | $5,106.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $560.27 / $5,106.14 / $6,681.00
| Professional | | $560.27 | $5,106.14 | $6,681.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $592.66 / $890.80 / $5,106.14
| Facility | | $592.66 | $890.80 | $5,106.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $560.27 / $5,106.14 / $6,681.00
| Professional | | $560.27 | $5,106.14 | $6,681.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,091.96 / $2,091.96 / $3,486.60
| Professional | | $2,091.96 | $2,091.96 | $3,486.60 |