- 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
- $2,042.28 / $2,042.28 / $2,042.28
| Professional | | $2,042.28 | $2,042.28 | $2,042.28 |
- 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
- $10,798.05 / $10,798.05 / $10,798.05
| Facility | | $10,798.05 | $10,798.05 | $10,798.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $847.44 / $847.44 / $2,042.28
| Professional | | $847.44 | $847.44 | $2,042.28 |