- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $3,109.00 / $9,477.00
| Facility | | $1,277.00 | $3,109.00 | $9,477.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,661.97 / $5,971.88 / $6,685.21
| Professional | | $4,661.97 | $5,971.88 | $6,685.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,748.02 / $6,284.14 / $6,284.14
| Professional | | $4,748.02 | $6,284.14 | $6,284.14 |
- 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
- $3,808.81 / $5,055.22 / $9,939.71
| Professional | | $3,808.81 | $5,055.22 | $9,939.71 |