- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $4,116.39 / $4,116.39
| Facility | | $1,400.00 | $4,116.39 | $4,116.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,734.13 / $4,116.39 / $4,931.31
| Professional | | $3,734.13 | $4,116.39 | $4,931.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,697.63 / $4,697.63 / $4,697.63
| Facility | | $4,697.63 | $4,697.63 | $4,697.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,013.70 / $5,768.65 / $19,468.50
| Professional | | $4,013.70 | $5,768.65 | $19,468.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,155.10 / $4,535.46 / $7,423.17
| Professional | | $3,155.10 | $4,535.46 | $7,423.17 |