- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,615.00 / $7,186.00 / $10,561.00
| Facility | | $1,615.00 | $7,186.00 | $10,561.00 |
- 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
- $1,766.45 / $1,811.41 / $2,173.69
| Facility | | $1,766.45 | $1,811.41 | $2,173.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,526.00 / $7,659.00 / $10,502.00
| Facility | | $2,526.00 | $7,659.00 | $10,502.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |