- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,100.00 / $1,746.00 / $2,729.00
| Facility | | $1,100.00 | $1,746.00 | $2,729.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,091.44 / $1,366.83 / $1,945.30
| Professional | | $1,091.44 | $1,366.83 | $1,945.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,714.86 / $4,508.14 / $6,064.91
| Facility | | $3,714.86 | $4,508.14 | $6,064.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,751.00 / $16,052.00 / $28,754.00
| Facility | | $7,751.00 | $16,052.00 | $28,754.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,466.78 / $1,839.08 / $2,398.80
| Professional | | $1,466.78 | $1,839.08 | $2,398.80 |