- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $10,000.00 / $14,125.38
| Facility | | $4,570.88 | $10,000.00 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,819.70 / $2,818.38
| Professional | | $1,288.25 | $1,819.70 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $489.78 / $489.78
| Professional | | $489.78 | $489.78 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,187.76 / $4,168.69
| Professional | | $1,621.81 | $2,187.76 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $17,782.79 / $41,686.94
| Facility | | $6,456.54 | $17,782.79 | $41,686.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,949.84 / $3,630.78
| Professional | | $1,380.38 | $1,949.84 | $3,630.78 |