- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $343.85 / $2,084.44 / $10,000.00
| Facility | | $343.85 | $2,084.44 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.36 / $1,937.62 / $2,589.73
| Professional | | $324.36 | $1,937.62 | $2,589.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $670.68 / $865.08 / $3,962.94
| Professional | | $670.68 | $865.08 | $3,962.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $469.60 / $982.09 / $5,417.84
| Professional | | $469.60 | $982.09 | $5,417.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $343.85 / $2,084.44 / $3,543.57
| Facility | | $343.85 | $2,084.44 | $3,543.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,105.83 / $4,047.21 / $5,476.36
| Professional | | $2,105.83 | $4,047.21 | $5,476.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,411.27 / $4,310.70 / $5,476.36
| Professional | | $2,411.27 | $4,310.70 | $5,476.36 |