- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,873.00 / $3,873.00 / $3,873.00
| Facility | | $3,873.00 | $3,873.00 | $3,873.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,826.52 / $3,873.00 / $3,873.00
| Professional | | $3,826.52 | $3,873.00 | $3,873.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,841.25 / $6,003.00 / $12,394.00
| Professional | | $4,841.25 | $6,003.00 | $12,394.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,299.59 / $6,299.59 / $6,299.59
| Professional | | $6,299.59 | $6,299.59 | $6,299.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.66 / $1,626.66 / $3,873.00
| Professional | | $1,626.66 | $1,626.66 | $3,873.00 |