- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,546.15 / $2,546.15 / $8,500.00
| Facility | | $2,546.15 | $2,546.15 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,546.15 / $3,493.25 / $3,735.91
| Professional | | $2,546.15 | $3,493.25 | $3,735.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,210.23 / $3,580.50 / $6,474.85
| Facility | | $1,210.23 | $3,580.50 | $6,474.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,613.94 / $6,276.87 / $10,016.75
| Professional | | $3,613.94 | $6,276.87 | $10,016.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,538.73 / $5,288.70 / $10,016.75
| Professional | | $3,538.73 | $5,288.70 | $10,016.75 |