- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,225.82 / $1,225.82 / $8,500.00
| Facility | | $1,225.82 | $1,225.82 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,225.82 / $1,225.82 / $1,519.91
| Professional | | $1,225.82 | $1,225.82 | $1,519.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,019.01 / $1,225.82 / $5,230.72
| Facility | | $1,019.01 | $1,225.82 | $5,230.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.93 / $3,340.99 / $4,711.87
| Professional | | $1,902.93 | $3,340.99 | $4,711.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,283.19 / $3,644.90 / $4,711.87
| Professional | | $1,283.19 | $3,644.90 | $4,711.87 |