- 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
- $475.87 / $2,390.00 / $10,957.50
| Facility | | $475.87 | $2,390.00 | $10,957.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $475.87 / $475.87 / $475.87
| Professional | | $475.87 | $475.87 | $475.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,129.22 / $1,352.93 / $1,628.96
| Professional | | $1,129.22 | $1,352.93 | $1,628.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,286.38 / $2,504.21 / $2,504.21
| Professional | | $1,286.38 | $2,504.21 | $2,504.21 |