- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $900.00 / $3,006.37 / $4,050.00
| Facility | | $900.00 | $3,006.37 | $4,050.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,006.37 / $3,006.37 / $3,006.37
| Professional | | $3,006.37 | $3,006.37 | $3,006.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,463.38 / $5,028.43 / $7,616.95
| Facility | | $2,463.38 | $5,028.43 | $7,616.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $746.00 / $2,415.00 / $6,585.00
| Facility | | $746.00 | $2,415.00 | $6,585.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,733.17 / $2,644.24 / $4,576.18
| Professional | | $1,733.17 | $2,644.24 | $4,576.18 |