- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $568.92 / $5,000.00 / $9,854.06
| Facility | | $568.92 | $5,000.00 | $9,854.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.52 / $3,238.79 / $11,952.67
| Professional | | $562.52 | $3,238.79 | $11,952.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,078.33 / $1,395.56 / $18,751.83
| Professional | | $1,078.33 | $1,395.56 | $18,751.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $787.87 / $10,579.94 / $20,867.96
| Professional | | $787.87 | $10,579.94 | $20,867.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $568.92 / $9,073.37 / $16,751.90
| Facility | | $568.92 | $9,073.37 | $16,751.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,873.39 / $18,398.38 / $25,968.47
| Professional | | $9,873.39 | $18,398.38 | $25,968.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,873.39 / $19,596.20 / $25,968.47
| Professional | | $9,873.39 | $19,596.20 | $25,968.47 |