- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $1,688.00 / $9,034.00
| Facility | | $1,277.00 | $1,688.00 | $9,034.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,049.55 / $1,414.55 / $1,672.23
| Professional | | $1,049.55 | $1,414.55 | $1,672.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,228.42 / $1,535.53 / $1,625.85
| Professional | | $1,228.42 | $1,535.53 | $1,625.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,271.57 / $1,801.79 / $2,160.81
| Professional | | $1,271.57 | $1,801.79 | $2,160.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,104.00 / $4,555.00 / $8,929.00
| Facility | | $2,104.00 | $4,555.00 | $8,929.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.58 / $1,409.85 / $2,189.34
| Professional | | $1,066.58 | $1,409.85 | $2,189.34 |