- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,140.00 / $3,140.00 / $6,907.00
| Facility | | $3,140.00 | $3,140.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.13 / $1,255.10 / $1,255.10
| Professional | | $1,195.13 | $1,255.10 | $1,255.10 |
- 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
- $1,139.45 / $1,399.60 / $2,410.26
| Professional | | $1,139.45 | $1,399.60 | $2,410.26 |
- 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
- $1,071.03 / $1,400.07 / $2,980.31
| Professional | | $1,071.03 | $1,400.07 | $2,980.31 |