- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,140.00 / $4,178.70 / $6,907.00
| Facility | | $3,140.00 | $4,178.70 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $447.00 / $447.00 / $1,000.00
| Professional | | $447.00 | $447.00 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,113.20 / $5,113.20 / $6,032.48
| Facility | | $5,113.20 | $5,113.20 | $6,032.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,821.05 / $1,821.05 / $1,821.05
| Professional | | $1,821.05 | $1,821.05 | $1,821.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.00 / $143.00 / $143.00
| Facility | | $143.00 | $143.00 | $143.00 |