- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,129.63 / $1,129.63 / $10,000.00
| Facility | | $1,129.63 | $1,129.63 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $961.75 / $1,122.59 / $1,168.78
| Professional | | $961.75 | $1,122.59 | $1,168.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,225.40 / $2,493.60 / $2,933.65
| Professional | | $2,225.40 | $2,493.60 | $2,933.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.17 / $2,749.43 / $3,662.24
| Professional | | $1,412.17 | $2,749.43 | $3,662.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,129.63 / $1,398.59 / $1,920.37
| Facility | | $1,129.63 | $1,398.59 | $1,920.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,190.59 / $2,112.30 / $2,919.74
| Professional | | $1,190.59 | $2,112.30 | $2,919.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,859.81 / $13,859.81 / $13,859.81
| Facility | | $13,859.81 | $13,859.81 | $13,859.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,190.59 / $2,112.30 / $2,438.08
| Professional | | $1,190.59 | $2,112.30 | $2,438.08 |