- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,181.00 / $2,477.00 / $9,477.00
| Facility | | $1,181.00 | $2,477.00 | $9,477.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,732.59 / $3,006.37 / $3,006.37
| Professional | | $1,732.59 | $3,006.37 | $3,006.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,875.60 / $2,875.60 / $3,450.72
| Facility | | $2,875.60 | $2,875.60 | $3,450.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,347.12 / $5,347.12 / $5,347.12
| Facility | | $5,347.12 | $5,347.12 | $5,347.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $980.00 / $1,650.00 / $4,233.00
| Facility | | $980.00 | $1,650.00 | $4,233.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,421.91 / $2,061.66 / $3,481.89
| Professional | | $1,421.91 | $2,061.66 | $3,481.89 |