- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,651.66 / $3,651.66 / $3,651.66
| Facility | | $3,651.66 | $3,651.66 | $3,651.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,651.66 / $3,651.66 / $3,651.66
| Professional | | $3,651.66 | $3,651.66 | $3,651.66 |
- 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
- $45.00 / $60.00 / $481.34
| Professional | | $45.00 | $60.00 | $481.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,179.60 / $5,150.12 / $5,420.95
| Professional | | $4,179.60 | $5,150.12 | $5,420.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,666.33 / $3,666.33 / $3,666.33
| Professional | | $3,666.33 | $3,666.33 | $3,666.33 |