- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $3,715.35 / $10,000.00
| Facility | | $1,071.52 | $3,715.35 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $891.25 / $1,995.26
| Professional | | $741.31 | $891.25 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $8,511.38 / $28,840.32
| Facility | | $2,818.38 | $8,511.38 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,023.29 / $1,949.84
| Professional | | $707.95 | $1,023.29 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,884.03 / $19,952.62
| Facility | | $1,348.96 | $2,884.03 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,202.26 / $2,630.27
| Professional | | $758.58 | $1,202.26 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $11,748.98 / $28,840.32
| Facility | | $3,715.35 | $11,748.98 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,000.00 / $1,819.70
| Professional | | $691.83 | $1,000.00 | $1,819.70 |