- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $874.74 / $1,821.00 / $9,477.00
| Facility | | $874.74 | $1,821.00 | $9,477.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $874.74 / $874.74 / $1,616.44
| Professional | | $874.74 | $874.74 | $1,616.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,500.00 / $9,073.00
| Facility | | $2,000.00 | $2,500.00 | $9,073.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $1,056.00 / $2,558.00
| Facility | | $375.00 | $1,056.00 | $2,558.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,265.02 / $1,794.04 / $2,601.09
| Professional | | $1,265.02 | $1,794.04 | $2,601.09 |