- 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
- $1,457.98 / $3,183.00 / $13,009.50
| Facility | | $1,457.98 | $3,183.00 | $13,009.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,457.98 / $1,457.98 / $1,457.98
| Professional | | $1,457.98 | $1,457.98 | $1,457.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,387.65 / $4,058.79 / $4,886.89
| Professional | | $3,387.65 | $4,058.79 | $4,886.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,859.15 / $7,748.09 / $7,748.09
| Professional | | $3,859.15 | $7,748.09 | $7,748.09 |