- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,351.00 / $4,314.00 / $5,962.00
| Facility | | $2,351.00 | $4,314.00 | $5,962.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,533.07 / $2,533.07 / $2,533.07
| Facility | | $2,533.07 | $2,533.07 | $2,533.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.00 / $70.00 / $70.00
| Professional | | $65.00 | $70.00 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,251.62 / $2,533.07 / $2,533.07
| Facility | | $2,251.62 | $2,533.07 | $2,533.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,293.22 / $3,293.22 / $3,293.22
| Professional | | $3,293.22 | $3,293.22 | $3,293.22 |