- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,737.80 / $2,187.76
| Facility | | $1,584.89 | $1,737.80 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,698.24 / $2,570.40
| Professional | | $1,288.25 | $1,698.24 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,137.96 / $2,137.96
| Professional | | $1,096.48 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $4,365.16 / $7,585.78
| Facility | | $1,380.38 | $4,365.16 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Professional | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,000.00 / $10,000.00 / $10,000.00
| Facility | | $10,000.00 | $10,000.00 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,471.29 / $15,848.93 / $15,848.93
| Professional | | $10,471.29 | $15,848.93 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,137.96 / $2,137.96
| Facility | | $758.58 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,288.25 / $2,137.96
| Professional | | $891.25 | $1,288.25 | $2,137.96 |