- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,472.30 / $4,933.00 / $5,757.00
| Facility | | $1,472.30 | $4,933.00 | $5,757.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $929.70 / $1,472.30 / $1,472.30
| Professional | | $929.70 | $1,472.30 | $1,472.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,734.49 / $9,734.49 / $9,734.49
| Facility | | $9,734.49 | $9,734.49 | $9,734.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,247.77 / $10,123.87 / $12,654.84
| Professional | | $9,247.77 | $10,123.87 | $12,654.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,641.71 / $4,933.00 / $5,757.00
| Facility | | $1,641.71 | $4,933.00 | $5,757.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.30 / $1,641.71 / $2,090.02
| Professional | | $1,472.30 | $1,641.71 | $2,090.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,000.00 / $10,359.00 / $12,767.00
| Facility | | $5,000.00 | $10,359.00 | $12,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.10 / $1,947.75 / $2,626.15
| Professional | | $1,778.10 | $1,947.75 | $2,626.15 |