- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $900.00 / $2,562.00 / $4,050.00
| Facility | | $900.00 | $2,562.00 | $4,050.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,173.29 / $1,875.32 / $2,137.86
| Professional | | $1,173.29 | $1,875.32 | $2,137.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,508.59 / $5,645.46 / $11,636.81
| Facility | | $2,508.59 | $5,645.46 | $11,636.81 |
- 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
- $1,741.82 / $2,644.24 / $3,988.22
| Professional | | $1,741.82 | $2,644.24 | $3,988.22 |