- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,133.39 / $5,133.39 / $5,133.39
| Facility | | $5,133.39 | $5,133.39 | $5,133.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,133.39 / $5,133.39 / $5,133.39
| Professional | | $5,133.39 | $5,133.39 | $5,133.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,202.83 / $4,202.83 / $24,739.54
| Facility | | $4,202.83 | $4,202.83 | $24,739.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,362.26 / $4,202.83 / $4,202.83
| Professional | | $3,362.26 | $4,202.83 | $4,202.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,133.39 / $5,133.39 / $6,850.00
| Facility | | $5,133.39 | $5,133.39 | $6,850.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $815.75 / $815.75 / $815.75
| Professional | | $815.75 | $815.75 | $815.75 |