- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,930.00 / $6,071.00 / $13,151.00
| Facility | | $1,930.00 | $6,071.00 | $13,151.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,811.41 / $1,811.41 / $1,811.41
| Professional | | $1,811.41 | $1,811.41 | $1,811.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.30 / $2,116.30 / $2,116.30
| Professional | | $2,116.30 | $2,116.30 | $2,116.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,521.00 / $2,083.12 / $5,562.00
| Facility | | $1,521.00 | $2,083.12 | $5,562.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,436.00 / $3,096.00 / $5,565.00
| Facility | | $1,436.00 | $3,096.00 | $5,565.00 |