- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,520.00 / $6,441.60 / $7,145.60
| Facility | | $3,520.00 | $6,441.60 | $7,145.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,520.00 / $3,520.00 / $3,520.00
| Facility | | $3,520.00 | $3,520.00 | $3,520.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,520.00 / $3,520.00 / $3,520.00
| Professional | | $3,520.00 | $3,520.00 | $3,520.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,288.00 / $2,402.40 / $2,670.10
| Facility | | $2,288.00 | $2,402.40 | $2,670.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.47 / $2,758.71 / $5,056.14
| Professional | | $16.47 | $2,758.71 | $5,056.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,478.40 / $1,760.00 / $5,280.00
| Professional | | $1,478.40 | $1,760.00 | $5,280.00 |