- 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
- $1,859.07 / $3,183.00 / $13,009.50
| Facility | | $1,859.07 | $3,183.00 | $13,009.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,859.07 / $1,859.07 / $1,859.07
| Professional | | $1,859.07 | $1,859.07 | $1,859.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,298.18 / $5,149.72 / $6,200.40
| Professional | | $4,298.18 | $5,149.72 | $6,200.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,896.42 / $9,906.45 / $9,906.45
| Professional | | $4,896.42 | $9,906.45 | $9,906.45 |