- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $860.00 / $2,500.00 / $5,150.00
| Facility | | $860.00 | $2,500.00 | $5,150.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,708.18 / $2,383.58 / $2,946.37
| Professional | | $1,708.18 | $2,383.58 | $2,946.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,600.21 / $7,788.50 / $11,438.03
| Facility | | $4,600.21 | $7,788.50 | $11,438.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,891.92 / $2,217.31 / $2,827.42
| Professional | | $1,891.92 | $2,217.31 | $2,827.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,533.26 / $2,154.51 / $3,036.36
| Professional | | $1,533.26 | $2,154.51 | $3,036.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,141.00 / $4,717.00 / $10,810.00
| Facility | | $1,141.00 | $4,717.00 | $10,810.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,462.11 / $2,366.83 / $3,405.65
| Professional | | $1,462.11 | $2,366.83 | $3,405.65 |