- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,486.00 / $8,114.00 / $15,915.00
| Facility | | $5,486.00 | $8,114.00 | $15,915.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,180.97 / $2,811.58 / $5,719.41
| Facility | | $2,180.97 | $2,811.58 | $5,719.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.31 / $2,834.73 / $3,221.29
| Professional | | $1,949.31 | $2,834.73 | $3,221.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,800.00 / $1,800.00 / $1,800.00
| Facility | | $1,800.00 | $1,800.00 | $1,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $51.00
| Professional | | $30.00 | $30.00 | $51.00 |