- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,657.49 / $3,657.49 / $3,657.49
| Facility | | $3,657.49 | $3,657.49 | $3,657.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $390.93 / $3,657.49 / $5,198.76
| Professional | | $390.93 | $3,657.49 | $5,198.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,652.80 / $3,316.00 / $6,273.12
| Facility | | $2,652.80 | $3,316.00 | $6,273.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $390.93 / $3,657.49 / $5,198.76
| Professional | | $390.93 | $3,657.49 | $5,198.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,866.56 / $1,866.56 / $2,215.92
| Professional | | $1,866.56 | $1,866.56 | $2,215.92 |