- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,818.66 / $3,818.66 / $3,818.66
| Facility | | $3,818.66 | $3,818.66 | $3,818.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $738.67 / $3,818.66 / $6,943.20
| Professional | | $738.67 | $3,818.66 | $6,943.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,818.66 / $6,622.15 / $8,378.08
| Facility | | $3,818.66 | $6,622.15 | $8,378.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $738.67 / $3,818.66 / $6,943.20
| Professional | | $738.67 | $3,818.66 | $6,943.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,670.54 / $2,954.68 / $3,382.28
| Professional | | $2,670.54 | $2,954.68 | $3,382.28 |