- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,747.00 / $4,889.50 / $9,673.50
| Facility | | $2,747.00 | $4,889.50 | $9,673.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,520.23 / $3,520.23 / $3,520.23
| Professional | | $3,520.23 | $3,520.23 | $3,520.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,093.00 / $9,458.00 / $16,490.00
| Facility | | $6,093.00 | $9,458.00 | $16,490.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.03 / $233.03 / $233.03
| Professional | | $233.03 | $233.03 | $233.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $714.97 / $765.00 / $842.00
| Facility | | $714.97 | $765.00 | $842.00 |