- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,262.25 / $1,262.25 / $9,058.50
| Facility | | $1,262.25 | $1,262.25 | $9,058.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.00 / $1,232.55 / $1,262.25
| Professional | | $1,188.00 | $1,232.55 | $1,262.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,262.25 / $1,262.25 / $1,670.63
| Professional | | $1,262.25 | $1,262.25 | $1,670.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,556.60 / $5,574.94 / $13,785.00
| Facility | | $2,556.60 | $5,574.94 | $13,785.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,262.25 / $1,262.25 / $1,262.25
| Professional | | $1,262.25 | $1,262.25 | $1,262.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,849.57 / $2,601.46 / $2,662.85
| Facility | | $1,849.57 | $2,601.46 | $2,662.85 |