- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $296.57 / $1,534.09 / $10,000.00
| Facility | | $296.57 | $1,534.09 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.48 / $1,373.46 / $1,780.02
| Professional | | $285.48 | $1,373.46 | $1,780.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $570.73 / $2,142.84 / $2,966.59
| Professional | | $570.73 | $2,142.84 | $2,966.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $408.06 / $909.38 / $3,442.61
| Professional | | $408.06 | $909.38 | $3,442.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $296.57 / $1,534.09 / $4,602.27
| Facility | | $296.57 | $1,534.09 | $4,602.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,549.33 / $2,814.29 / $4,029.80
| Professional | | $1,549.33 | $2,814.29 | $4,029.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,670.38 / $2,979.72 / $4,029.80
| Professional | | $1,670.38 | $2,979.72 | $4,029.80 |