- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,028.41 / $1,028.41 / $10,000.00
| Facility | | $1,028.41 | $1,028.41 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $866.94 / $958.29 / $1,074.15
| Professional | | $866.94 | $958.29 | $1,074.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,000.87 / $2,160.90 / $2,589.36
| Professional | | $2,000.87 | $2,160.90 | $2,589.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,491.01 / $2,414.67 / $3,118.21
| Professional | | $1,491.01 | $2,414.67 | $3,118.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,028.41 / $1,257.48 / $1,748.30
| Facility | | $1,028.41 | $1,257.48 | $1,748.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,076.55 / $1,793.41 / $7,552.64
| Professional | | $1,076.55 | $1,793.41 | $7,552.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,076.55 / $1,609.66 / $2,539.17
| Professional | | $1,076.55 | $1,609.66 | $2,539.17 |