- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,248.00 / $4,838.00 / $11,446.00
| Facility | | $3,248.00 | $4,838.00 | $11,446.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $732.26 / $4,275.50 / $16,534.50
| Facility | | $732.26 | $4,275.50 | $16,534.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $732.26 / $732.26 / $732.26
| Professional | | $732.26 | $732.26 | $732.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,715.93 / $2,055.88 / $2,475.34
| Professional | | $1,715.93 | $2,055.88 | $2,475.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,954.76 / $3,868.38 / $3,868.38
| Professional | | $1,954.76 | $3,868.38 | $3,868.38 |