- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,614.00 / $4,144.00 / $8,043.00
| Facility | | $1,614.00 | $4,144.00 | $8,043.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.71 / $2,398.71 / $2,398.71
| Professional | | $2,398.71 | $2,398.71 | $2,398.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,410.01 / $5,220.03 / $5,220.03
| Professional | | $2,410.01 | $5,220.03 | $5,220.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.00 / $1,319.00 / $16,382.00
| Facility | | $645.00 | $1,319.00 | $16,382.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,017.56 / $4,401.58 / $6,424.92
| Professional | | $2,017.56 | $4,401.58 | $6,424.92 |