- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,777.87 / $1,777.87 / $8,500.00
| Facility | | $1,777.87 | $1,777.87 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,777.87 / $1,777.87 / $1,918.93
| Professional | | $1,777.87 | $1,777.87 | $1,918.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $594.75 / $594.75 / $743.44
| Professional | | $594.75 | $594.75 | $743.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $287.63 / $1,777.87 / $5,333.61
| Facility | | $287.63 | $1,777.87 | $5,333.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,796.15 / $4,773.14 / $6,567.89
| Professional | | $2,796.15 | $4,773.14 | $6,567.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,796.15 / $5,083.89 / $6,567.89
| Professional | | $2,796.15 | $5,083.89 | $6,567.89 |