- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,562.00 / $5,363.00 / $7,421.00
| Facility | | $3,562.00 | $5,363.00 | $7,421.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,562.00 / $5,595.00 / $6,915.00
| Professional | | $3,562.00 | $5,595.00 | $6,915.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,491.93 / $4,469.68 / $9,523.08
| Facility | | $1,491.93 | $4,469.68 | $9,523.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,887.80 / $2,359.75 / $2,359.75
| Professional | | $1,887.80 | $2,359.75 | $2,359.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $607.00 / $3,629.00 / $10,000.00
| Facility | | $607.00 | $3,629.00 | $10,000.00 |