- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Facility | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $6,918.31
| Professional | | $5,128.61 | $5,128.61 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $645.65 / $676.08
| Professional | | $549.54 | $645.65 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,754.40 / $7,079.46
| Professional | | $5,623.41 | $5,754.40 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $79.43 / $5,128.61 / $6,918.31
| Facility | | $79.43 | $5,128.61 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $446.68 / $501.19
| Professional | | $398.11 | $446.68 | $501.19 |