- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $860.00 / $2,636.00 / $5,526.00
| Facility | | $860.00 | $2,636.00 | $5,526.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.10 / $1,085.11 / $1,085.11
| Professional | | $1,085.10 | $1,085.11 | $1,085.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,542.72 / $7,776.15 / $11,550.02
| Facility | | $4,542.72 | $7,776.15 | $11,550.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,265.42 / $9,265.42 / $9,265.42
| Facility | | $9,265.42 | $9,265.42 | $9,265.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $488.00 / $675.00 / $1,100.00
| Facility | | $488.00 | $675.00 | $1,100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $929.00 / $929.00 / $3,562.26
| Professional | | $929.00 | $929.00 | $3,562.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,172.00 / $6,182.00 / $12,795.57
| Facility | | $1,172.00 | $6,182.00 | $12,795.57 |