- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $3,899.23 / $3,899.23
| Facility | | $1,400.00 | $3,899.23 | $3,899.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,537.13 / $3,899.23 / $4,671.06
| Professional | | $3,537.13 | $3,899.23 | $4,671.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,449.77 / $4,449.77 / $4,449.77
| Facility | | $4,449.77 | $4,449.77 | $4,449.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.84 / $5,464.33 / $18,441.03
| Professional | | $3,801.84 | $5,464.33 | $18,441.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,988.70 / $4,894.10 / $7,031.73
| Professional | | $2,988.70 | $4,894.10 | $7,031.73 |