- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $497.00 / $1,320.00 / $3,685.00
| Facility | | $497.00 | $1,320.00 | $3,685.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,219.92 / $3,492.45 / $3,981.39
| Professional | | $3,219.92 | $3,492.45 | $3,981.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,417.02 / $2,460.69 / $3,560.43
| Facility | | $1,417.02 | $2,460.69 | $3,560.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $500.00 / $1,752.00 / $4,123.00
| Facility | | $500.00 | $1,752.00 | $4,123.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,270.18 / $4,675.84 / $7,475.84
| Professional | | $3,270.18 | $4,675.84 | $7,475.84 |