- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,057.00 / $7,773.00 / $13,152.00
| Facility | | $5,057.00 | $7,773.00 | $13,152.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.48 / $1,000.48 / $1,000.48
| Professional | | $1,000.48 | $1,000.48 | $1,000.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $58.40 / $70.00
| Professional | | $50.00 | $58.40 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,998.05 / $10,998.05 / $10,998.05
| Facility | | $10,998.05 | $10,998.05 | $10,998.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.38 / $585.38 / $1,000.48
| Professional | | $585.38 | $585.38 | $1,000.48 |