- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $3,890.45 / $10,000.00
| Facility | | $1,174.90 | $3,890.45 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,122.02 / $2,754.23
| Professional | | $933.25 | $1,122.02 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $7,413.10 / $16,218.10
| Facility | | $2,570.40 | $7,413.10 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,288.25 / $2,511.89
| Professional | | $870.96 | $1,288.25 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,570.40 / $7,244.36
| Facility | | $1,230.27 | $2,570.40 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,513.56 / $3,162.28
| Professional | | $977.24 | $1,513.56 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $7,244.36 / $16,218.10
| Facility | | $2,454.71 | $7,244.36 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,230.27 / $2,290.87
| Professional | | $870.96 | $1,230.27 | $2,290.87 |