- 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
- $411.25 / $7,157.00 / $8,057.17
| Professional | | $411.25 | $7,157.00 | $8,057.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,876.62 / $2,876.62 / $5,647.00
| Facility | | $2,876.62 | $2,876.62 | $5,647.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $662.70 / $662.70 / $662.70
| Professional | | $662.70 | $662.70 | $662.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,027.00 / $1,485.00 / $1,485.00
| Facility | | $1,027.00 | $1,485.00 | $1,485.00 |