- 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
- $2,393.39 / $2,393.39 / $2,393.39
| Facility | | $2,393.39 | $2,393.39 | $2,393.39 |
- 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
- $2,127.46 / $2,393.39 / $2,393.39
| Facility | | $2,127.46 | $2,393.39 | $2,393.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,111.60 / $3,111.60 / $3,111.60
| Professional | | $3,111.60 | $3,111.60 | $3,111.60 |