- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,435.00 / $4,456.05 / $4,943.05
| Facility | | $2,435.00 | $4,456.05 | $4,943.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,923.65 / $4,456.05 / $4,943.05
| Professional | | $1,923.65 | $4,456.05 | $4,943.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,435.00 / $2,435.00 / $2,435.00
| Facility | | $2,435.00 | $2,435.00 | $2,435.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,435.00 / $2,435.00 / $2,435.00
| Professional | | $2,435.00 | $2,435.00 | $2,435.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $20.00 / $42.50
| Professional | | $17.00 | $20.00 | $42.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,022.70 / $1,461.00 / $3,907.08
| Professional | | $1,022.70 | $1,461.00 | $3,907.08 |