- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,073.69 / $3,109.00 / $9,477.00
| Facility | | $1,073.69 | $3,109.00 | $9,477.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,073.69 / $1,073.69 / $2,036.64
| Professional | | $1,073.69 | $1,073.69 | $2,036.64 |
- 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
- $1,702.09 / $2,256.86 / $3,580.20
| Professional | | $1,702.09 | $2,256.86 | $3,580.20 |