- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $762.00 / $1,850.00 / $3,945.00
| Facility | | $762.00 | $1,850.00 | $3,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,343.93 / $1,432.25 / $1,904.88
| Professional | | $1,343.93 | $1,432.25 | $1,904.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,587.72 / $20,228.16 / $30,643.25
| Facility | | $10,587.72 | $20,228.16 | $30,643.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,215.00 / $8,932.00 / $19,270.00
| Facility | | $1,215.00 | $8,932.00 | $19,270.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,104.41 / $1,844.00 / $2,968.99
| Professional | | $1,104.41 | $1,844.00 | $2,968.99 |