- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $10,000.00 / $20,417.38
| Facility | | $2,344.23 | $10,000.00 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,890.45 / $3,981.07
| Professional | | $3,801.89 | $3,890.45 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $5,623.41
| Facility | | $3,890.45 | $3,890.45 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $3,890.45 / $6,760.83
| Professional | | $60.26 | $3,890.45 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,897.79 / $5,623.41
| Facility | | $3,890.45 | $4,897.79 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $2,238.72
| Professional | | $60.26 | $60.26 | $2,238.72 |