- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,200.00 / $3,821.00 / $12,600.00
| Facility | | $1,200.00 | $3,821.00 | $12,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,683.00 / $5,946.00 / $6,422.00
| Professional | | $3,683.00 | $5,946.00 | $6,422.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,756.91 / $6,756.91 / $6,756.91
| Professional | | $6,756.91 | $6,756.91 | $6,756.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,960.00 / $9,469.00 / $20,423.23
| Facility | | $1,960.00 | $9,469.00 | $20,423.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,228.00 / $11,829.54 / $20,423.23
| Facility | | $3,228.00 | $11,829.54 | $20,423.23 |