- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.94 / $183.94 / $183.94
| Professional | | $183.94 | $183.94 | $183.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,581.16 / $4,581.16 / $5,931.88
| Facility | | $4,581.16 | $4,581.16 | $5,931.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,581.16 / $4,581.16 / $4,581.16
| Professional | | $4,581.16 | $4,581.16 | $4,581.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,581.16 / $4,581.16 / $5,931.88
| Facility | | $4,581.16 | $4,581.16 | $5,931.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,791.30 / $3,949.28 / $4,581.16
| Professional | | $3,791.30 | $3,949.28 | $4,581.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.96 / $1,326.96 / $3,159.42
| Professional | | $1,326.96 | $1,326.96 | $3,159.42 |