- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,085.11 / $1,085.11 / $4,338.00
| Facility | | $1,085.11 | $1,085.11 | $4,338.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.10 / $1,085.11 / $2,529.38
| Professional | | $1,085.10 | $1,085.11 | $2,529.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,833.85 / $1,833.85 / $4,500.00
| Facility | | $1,833.85 | $1,833.85 | $4,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.00 / $500.00 / $500.00
| Professional | | $500.00 | $500.00 | $500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,500.00 / $4,500.00 / $4,500.00
| Facility | | $4,500.00 | $4,500.00 | $4,500.00 |