- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $2,454.71 / $10,000.00
| Facility | | $446.68 | $2,454.71 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $1,659.59 / $2,951.21
| Professional | | $389.05 | $1,659.59 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,122.02 / $5,011.87
| Professional | | $831.76 | $1,122.02 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,288.25 / $6,025.60
| Professional | | $616.60 | $1,288.25 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $1,318.26 / $4,168.69
| Facility | | $446.68 | $1,318.26 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,265.80 / $5,623.41
| Professional | | $2,454.71 | $4,265.80 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,041.74
| Facility | | $1,819.70 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $2,089.30 / $5,623.41
| Professional | | $501.19 | $2,089.30 | $5,623.41 |