- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $988.00 / $2,747.00 / $2,898.00
| Facility | | $988.00 | $2,747.00 | $2,898.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,531.45 / $13,531.45 / $13,531.45
| Professional | | $13,531.45 | $13,531.45 | $13,531.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,056.44 / $1,056.44 / $1,491.44
| Professional | | $1,056.44 | $1,056.44 | $1,491.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,078.00 / $1,078.00 / $1,078.00
| Facility | | $1,078.00 | $1,078.00 | $1,078.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $764.06 / $828.67 / $1,461.63
| Professional | | $764.06 | $828.67 | $1,461.63 |