- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,100.00 / $2,250.00 / $4,100.00
| Facility | | $1,100.00 | $2,250.00 | $4,100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,297.01 / $2,307.27 / $2,863.06
| Professional | | $1,297.01 | $2,307.27 | $2,863.06 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $971.35 / $1,330.61 / $1,570.12
| Professional | | $971.35 | $1,330.61 | $1,570.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,290.80 / $1,885.26 / $4,517.70
| Professional | | $1,290.80 | $1,885.26 | $4,517.70 |
- 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
- $1,062.48 / $1,444.57 / $2,233.56
| Professional | | $1,062.48 | $1,444.57 | $2,233.56 |