- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,282.89 / $3,282.89 / $3,282.89
| Facility | | $3,282.89 | $3,282.89 | $3,282.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $456.28 / $3,282.89 / $5,112.50
| Professional | | $456.28 | $3,282.89 | $5,112.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,282.89 / $4,306.22 / $8,180.00
| Facility | | $3,282.89 | $4,306.22 | $8,180.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $456.28 / $3,282.89 / $5,112.50
| Professional | | $456.28 | $3,282.89 | $5,112.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,607.38 / $2,859.96 / $4,766.60
| Professional | | $2,607.38 | $2,859.96 | $4,766.60 |