- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $3,548.13 / $8,317.64
| Professional | | $776.25 | $3,548.13 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $3,630.78 / $10,964.78
| Professional | | $1,047.13 | $3,630.78 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $3,981.07 / $10,000.00
| Professional | | $1,318.26 | $3,981.07 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $4,365.16 / $9,120.11
| Professional | | $1,318.26 | $4,365.16 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $2,089.30 / $10,000.00
| Professional | | $79.43 | $2,089.30 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,630.27 / $10,000.00
| Professional | | $1,479.11 | $2,630.27 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $3,235.94 / $9,772.37
| Professional | | $1,202.26 | $3,235.94 | $9,772.37 |