- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,274.33 / $1,274.33 / $8,500.00
| Facility | | $1,274.33 | $1,274.33 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $545.69 / $1,274.33 / $1,274.33
| Professional | | $545.69 | $1,274.33 | $1,274.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $483.94 / $626.29 / $5,006.45
| Professional | | $483.94 | $626.29 | $5,006.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $789.86 / $1,274.33 / $3,822.99
| Facility | | $789.86 | $1,274.33 | $3,822.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,196.40 / $3,557.53 / $4,898.35
| Professional | | $2,196.40 | $3,557.53 | $4,898.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,992.15 / $3,789.14 / $4,898.35
| Professional | | $1,992.15 | $3,789.14 | $4,898.35 |