- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,019.66 / $1,019.66 / $8,500.00
| Facility | | $1,019.66 | $1,019.66 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $598.76 / $1,019.66 / $1,019.66
| Professional | | $598.76 | $1,019.66 | $1,019.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,821.88 / $5,821.88 / $7,277.34
| Professional | | $5,821.88 | $5,821.88 | $7,277.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $755.82 / $1,019.66 / $3,058.98
| Facility | | $755.82 | $1,019.66 | $3,058.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $697.32 / $1,267.85 / $14,605.42
| Professional | | $697.32 | $1,267.85 | $14,605.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $760.72 / $1,267.85 / $14,605.42
| Professional | | $760.72 | $1,267.85 | $14,605.42 |