- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,117.00 / $3,162.00 / $4,100.00
| Facility | | $1,117.00 | $3,162.00 | $4,100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,768.23 / $3,768.23 / $3,768.23
| Professional | | $3,768.23 | $3,768.23 | $3,768.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,905.23 / $6,907.03 / $6,907.03
| Professional | | $2,905.23 | $6,907.03 | $6,907.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $808.00 / $6,580.00 / $26,408.00
| Facility | | $808.00 | $6,580.00 | $26,408.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,426.55 / $7,218.74 / $9,755.04
| Professional | | $3,426.55 | $7,218.74 | $9,755.04 |