- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,977.00 / $9,202.00 / $15,596.00
| Facility | | $4,977.00 | $9,202.00 | $15,596.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,190.82 / $2,390.00 / $10,957.50
| Facility | | $1,190.82 | $2,390.00 | $10,957.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,190.82 / $1,190.82 / $1,190.82
| Professional | | $1,190.82 | $1,190.82 | $1,190.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,766.28 / $3,314.32 / $3,990.53
| Professional | | $2,766.28 | $3,314.32 | $3,990.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,151.30 / $6,349.76 / $6,349.76
| Professional | | $3,151.30 | $6,349.76 | $6,349.76 |