- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,040.00 / $1,728.00 / $2,377.00
| Facility | | $1,040.00 | $1,728.00 | $2,377.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,803.11 / $2,236.06 / $5,083.20
| Professional | | $1,803.11 | $2,236.06 | $5,083.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,195.78 / $7,518.88 / $10,115.29
| Facility | | $6,195.78 | $7,518.88 | $10,115.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,404.00 / $4,852.00 / $9,624.00
| Facility | | $1,404.00 | $4,852.00 | $9,624.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,550.22 / $2,040.24 / $3,517.65
| Professional | | $1,550.22 | $2,040.24 | $3,517.65 |