- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $8,511.38 / $14,125.38
| Facility | | $4,570.88 | $8,511.38 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,445.44 / $2,818.38
| Professional | | $1,148.15 | $1,445.44 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $14,125.38 / $16,595.87
| Facility | | $8,317.64 | $14,125.38 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,290.87 / $2,754.23
| Professional | | $1,148.15 | $2,290.87 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,737.80 / $3,715.35
| Professional | | $1,000.00 | $1,737.80 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,174.90 / $2,238.72
| Professional | | $691.83 | $1,174.90 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $10,471.29 / $16,218.10
| Facility | | $6,456.54 | $10,471.29 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,380.38 / $3,090.30
| Professional | | $1,000.00 | $1,380.38 | $3,090.30 |