- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,883.68 / $3,883.68 / $8,500.00
| Facility | | $3,883.68 | $3,883.68 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,745.79 / $3,883.68 / $3,883.68
| Professional | | $3,745.79 | $3,883.68 | $3,883.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,839.12 / $4,839.12 / $4,839.12
| Professional | | $4,839.12 | $4,839.12 | $4,839.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,883.68 / $3,883.68 / $11,651.04
| Facility | | $3,883.68 | $3,883.68 | $11,651.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,520.14 / $7,308.71 / $10,043.07
| Professional | | $4,520.14 | $7,308.71 | $10,043.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,281.50 / $7,784.54 / $10,043.07
| Professional | | $4,281.50 | $7,784.54 | $10,043.07 |