- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,511.00 / $3,511.00 / $4,338.00
| Facility | | $3,511.00 | $3,511.00 | $4,338.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,167.30 / $6,579.61 / $6,579.61
| Professional | | $1,167.30 | $6,579.61 | $6,579.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $696.76 / $696.76 / $696.76
| Professional | | $696.76 | $696.76 | $696.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,579.61 / $11,119.54 / $13,159.22
| Facility | | $6,579.61 | $11,119.54 | $13,159.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,714.00 / $2,714.00 / $2,714.00
| Facility | | $2,714.00 | $2,714.00 | $2,714.00 |