- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,989.00 / $9,750.00 / $16,411.00
| Facility | | $4,989.00 | $9,750.00 | $16,411.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,847.06 / $1,847.06 / $37,499.62
| Facility | | $1,847.06 | $1,847.06 | $37,499.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,847.06 / $1,847.06 / $1,847.06
| Professional | | $1,847.06 | $1,847.06 | $1,847.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,162.59 / $2,162.59 / $2,162.59
| Professional | | $2,162.59 | $2,162.59 | $2,162.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,941.81 / $2,436.32 / $5,243.32
| Professional | | $1,941.81 | $2,436.32 | $5,243.32 |