- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,092.65 / $1,768.00 / $4,100.00
| Facility | | $1,092.65 | $1,768.00 | $4,100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,092.65 / $1,092.65 / $1,339.15
| Professional | | $1,092.65 | $1,092.65 | $1,339.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,455.92 / $16,329.40 / $21,968.27
| Facility | | $13,455.92 | $16,329.40 | $21,968.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,250.00 / $11,123.00 / $13,458.00
| Facility | | $5,250.00 | $11,123.00 | $13,458.00 |
- 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
- $1,398.42 / $1,978.06 / $3,007.55
| Professional | | $1,398.42 | $1,978.06 | $3,007.55 |