- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,103.68 / $1,821.00 / $9,477.00
| Facility | | $1,103.68 | $1,821.00 | $9,477.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $536.72 / $1,103.68 / $2,086.58
| Professional | | $536.72 | $1,103.68 | $2,086.58 |
- 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
- $1,173.03 / $2,061.66 / $3,481.89
| Professional | | $1,173.03 | $2,061.66 | $3,481.89 |