- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,614.00 / $4,144.00 / $8,043.00
| Facility | | $1,614.00 | $4,144.00 | $8,043.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,322.27 / $2,322.27 / $2,322.27
| Professional | | $2,322.27 | $2,322.27 | $2,322.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,333.41 / $5,051.93 / $5,051.93
| Professional | | $2,333.41 | $5,051.93 | $5,051.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.00 / $1,319.00 / $16,382.00
| Facility | | $645.00 | $1,319.00 | $16,382.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,061.44 / $4,601.34 / $6,218.02
| Professional | | $2,061.44 | $4,601.34 | $6,218.02 |