- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,035.67 / $1,035.67 / $8,500.00
| Facility | | $1,035.67 | $1,035.67 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,035.67 / $1,035.67 / $1,431.66
| Professional | | $1,035.67 | $1,035.67 | $1,431.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,035.67 / $1,035.67 / $3,107.01
| Facility | | $1,035.67 | $1,035.67 | $3,107.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,693.70 / $2,891.23 / $3,981.00
| Professional | | $1,693.70 | $2,891.23 | $3,981.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.98 / $2,891.23 / $3,981.00
| Professional | | $1,618.98 | $2,891.23 | $3,981.00 |