- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,908.26 / $1,908.26 / $11,002.60
| Facility | | $1,908.26 | $1,908.26 | $11,002.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,908.26 / $1,908.26 / $1,908.26
| Professional | | $1,908.26 | $1,908.26 | $1,908.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,360.00 / $4,080.00 / $4,896.00
| Professional | | $3,360.00 | $4,080.00 | $4,896.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,300.60 / $4,300.60 / $4,300.60
| Facility | | $4,300.60 | $4,300.60 | $4,300.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,300.60 / $4,300.60 / $4,300.60
| Professional | | $4,300.60 | $4,300.60 | $4,300.60 |