- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,739.65 / $3,739.65 / $3,739.65
| Professional | | $3,739.65 | $3,739.65 | $3,739.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $661.71 / $830.61 / $2,166.96
| Facility | | $661.71 | $830.61 | $2,166.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,666.33 / $3,739.65 / $3,739.65
| Professional | | $3,666.33 | $3,739.65 | $3,739.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,739.65 / $3,739.65 / $3,739.65
| Facility | | $3,739.65 | $3,739.65 | $3,739.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,739.65 / $3,739.65 / $3,739.65
| Professional | | $3,739.65 | $3,739.65 | $3,739.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,739.65 / $3,739.65 / $4,480.47
| Professional | | $3,739.65 | $3,739.65 | $4,480.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,739.65 / $3,739.65 / $3,739.65
| Professional | | $3,739.65 | $3,739.65 | $3,739.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,666.33 / $3,666.33 / $5,316.18
| Professional | | $3,666.33 | $3,666.33 | $5,316.18 |