- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,112.21 / $3,109.00 / $9,477.00
| Facility | | $1,112.21 | $3,109.00 | $9,477.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,112.21 / $1,112.21 / $2,076.78
| Professional | | $1,112.21 | $1,112.21 | $2,076.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,125.00 / $7,875.00 / $9,992.00
| Facility | | $3,125.00 | $7,875.00 | $9,992.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $1,056.00 / $2,558.00
| Facility | | $375.00 | $1,056.00 | $2,558.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,605.05 / $2,373.52 / $3,610.83
| Professional | | $1,605.05 | $2,373.52 | $3,610.83 |