- 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
- $684.48 / $4,275.50 / $16,534.50
| Facility | | $684.48 | $4,275.50 | $16,534.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $684.48 / $684.48 / $684.48
| Professional | | $684.48 | $684.48 | $684.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,609.58 / $1,928.46 / $2,321.92
| Professional | | $1,609.58 | $1,928.46 | $2,321.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,833.61 / $3,631.67 / $3,631.67
| Professional | | $1,833.61 | $3,631.67 | $3,631.67 |