- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,878.45 / $7,097.57 / $7,873.26
| Facility | | $3,878.45 | $7,097.57 | $7,873.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,063.98 / $7,097.57 / $7,873.26
| Professional | | $3,063.98 | $7,097.57 | $7,873.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,878.45 / $3,878.45 / $3,878.45
| Facility | | $3,878.45 | $3,878.45 | $3,878.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,878.45 / $3,878.45 / $3,878.45
| Professional | | $3,878.45 | $3,878.45 | $3,878.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $40.00
| Professional | | $40.00 | $40.00 | $40.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,628.95 / $2,327.07 / $6,593.37
| Professional | | $1,628.95 | $2,327.07 | $6,593.37 |