- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,697.44 / $76,790.33 / $76,790.33
| Facility | | $3,697.44 | $76,790.33 | $76,790.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.82 / $3,697.44 / $3,893.61
| Professional | | $3,660.82 | $3,697.44 | $3,893.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,660.83 / $5,491.25 / $5,491.25
| Facility | | $3,660.83 | $5,491.25 | $5,491.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,453.62 / $3,660.83 / $3,827.86
| Facility | | $3,453.62 | $3,660.83 | $3,827.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,660.83 / $6,503.88
| Professional | | $3,660.83 | $3,660.83 | $6,503.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,660.83 / $4,611.45
| Professional | | $3,660.83 | $3,660.83 | $4,611.45 |