- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,328.00 / $8,303.41 / $13,413.92
| Facility | | $5,328.00 | $8,303.41 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,593.92 / $1,593.92 / $1,593.92
| Professional | | $1,593.92 | $1,593.92 | $1,593.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,593.92 / $2,231.48 / $2,279.31
| Facility | | $1,593.92 | $2,231.48 | $2,279.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,593.92 / $2,231.48 / $2,279.31
| Facility | | $1,593.92 | $2,231.48 | $2,279.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,458.25 / $3,627.46 / $8,343.16
| Professional | | $3,458.25 | $3,627.46 | $8,343.16 |