- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $4,168.69 / $10,000.00
| Facility | | $794.33 | $4,168.69 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $2,238.72 / $5,888.44
| Professional | | $758.58 | $2,238.72 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,238.72 / $9,549.93
| Professional | | $1,548.82 | $2,238.72 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $2,691.53 / $11,220.18
| Professional | | $912.01 | $2,691.53 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $2,454.71 / $7,244.36
| Facility | | $812.83 | $2,454.71 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $7,413.10 / $30,199.52
| Professional | | $3,890.45 | $7,413.10 | $30,199.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $8,912.51 / $11,481.54
| Facility | | $7,943.28 | $8,912.51 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,290.87 / $8,912.51
| Professional | | $1,000.00 | $2,290.87 | $8,912.51 |