- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,696.00 / $4,240.00 / $18,304.00
| Facility | | $1,696.00 | $4,240.00 | $18,304.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,696.00 / $2,496.00 / $2,720.00
| Professional | | $1,696.00 | $2,496.00 | $2,720.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,128.00 / $4,727.34 / $10,076.16
| Facility | | $3,128.00 | $4,727.34 | $10,076.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,360.00 / $4,192.00 / $5,830.40
| Professional | | $3,360.00 | $4,192.00 | $5,830.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,240.00 / $2,240.00 / $8,702.00
| Facility | | $2,240.00 | $2,240.00 | $8,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,240.00 / $2,240.00 / $2,240.00
| Professional | | $2,240.00 | $2,240.00 | $2,240.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,344.00 / $1,920.00 / $3,264.00
| Professional | | $1,344.00 | $1,920.00 | $3,264.00 |