- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.00 / $2,398.00 / $18,911.06
| Facility | | $2,398.00 | $2,398.00 | $18,911.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.00 / $2,398.00 / $2,398.00
| Professional | | $2,398.00 | $2,398.00 | $2,398.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,493.06 / $2,164.52 / $3,798.60
| Facility | | $1,493.06 | $2,164.52 | $3,798.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.00 / $2,398.00 / $4,556.20
| Facility | | $2,398.00 | $2,398.00 | $4,556.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,453.46 / $2,453.46 / $7,342.05
| Professional | | $2,453.46 | $2,453.46 | $7,342.05 |