- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $10,000.00
| Facility | | $1,122.02 | $1,122.02 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,122.02 / $2,630.27
| Professional | | $954.99 | $1,122.02 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,511.89 / $2,951.21
| Professional | | $1,995.26 | $2,511.89 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,137.96 / $3,467.37
| Professional | | $1,380.38 | $2,137.96 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,412.54 / $3,388.44
| Facility | | $1,122.02 | $1,412.54 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,041.74 / $8,511.38
| Professional | | $1,202.26 | $2,041.74 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,715.19 / $12,022.64 / $14,125.38
| Facility | | $10,715.19 | $12,022.64 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,041.74 / $2,754.23
| Professional | | $1,202.26 | $2,041.74 | $2,754.23 |