- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,275.05 / $5,693.00 / $12,175.00
| Facility | | $3,275.05 | $5,693.00 | $12,175.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,688.08 / $2,276.68 / $4,631.31
| Facility | | $1,688.08 | $2,276.68 | $4,631.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,420.94 / $2,900.57 / $3,492.36
| Professional | | $2,420.94 | $2,900.57 | $3,492.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.89 / $1,047.89 / $1,047.89
| Facility | | $1,047.89 | $1,047.89 | $1,047.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $1,810.00 / $5,349.00
| Professional | | $30.00 | $1,810.00 | $5,349.00 |