- 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
- $1,398.56 / $2,049.90 / $2,318.71
| Professional | | $1,398.56 | $2,049.90 | $2,318.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,484.66 / $21,218.47 / $28,545.63
| Facility | | $17,484.66 | $21,218.47 | $28,545.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $650.00 / $1,754.00 / $5,201.00
| Facility | | $650.00 | $1,754.00 | $5,201.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,784.00 / $2,259.73 / $3,879.86
| Professional | | $1,784.00 | $2,259.73 | $3,879.86 |