- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,736.00 / $4,736.00 / $6,907.00
| Facility | | $4,736.00 | $4,736.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,259.24 / $1,322.86 / $3,500.60
| Professional | | $1,259.24 | $1,322.86 | $3,500.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,389.76 / $3,389.76 / $3,389.76
| Facility | | $3,389.76 | $3,389.76 | $3,389.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,203.18 / $1,421.48 / $2,520.98
| Professional | | $1,203.18 | $1,421.48 | $2,520.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,530.00 / $2,530.00 / $2,530.00
| Facility | | $2,530.00 | $2,530.00 | $2,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,162.02 / $1,411.47 / $3,141.82
| Professional | | $1,162.02 | $1,411.47 | $3,141.82 |