- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,207.83 / $1,207.83 / $8,500.00
| Facility | | $1,207.83 | $1,207.83 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,207.83 / $1,328.41
| Professional | | $776.25 | $1,207.83 | $1,328.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,387.09 / $3,815.27 / $5,081.95
| Professional | | $2,387.09 | $3,815.27 | $5,081.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,207.83 / $1,843.14 / $2,632.43
| Facility | | $1,207.83 | $1,843.14 | $2,632.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.32 / $1,399.77 / $3,678.08
| Professional | | $927.32 | $1,399.77 | $3,678.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $998.65 / $1,426.64 / $2,799.54
| Professional | | $998.65 | $1,426.64 | $2,799.54 |