- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,876.75 / $3,876.75 / $4,430.57
| Facility | | $3,876.75 | $3,876.75 | $4,430.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,692.14 / $3,876.75 / $4,430.57
| Professional | | $3,692.14 | $3,876.75 | $4,430.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,692.14 / $3,692.14 / $3,692.14
| Facility | | $3,692.14 | $3,692.14 | $3,692.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,692.14 / $3,692.14 / $3,692.14
| Professional | | $3,692.14 | $3,692.14 | $3,692.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $25.00 / $50.00
| Professional | | $17.00 | $25.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,507.53 / $3,692.14 / $4,799.78
| Professional | | $3,507.53 | $3,692.14 | $4,799.78 |