- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $10,000.00 / $20,417.38
| Facility | | $2,344.23 | $10,000.00 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,318.26 / $4,677.35
| Professional | | $912.01 | $1,318.26 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $2,818.38
| Professional | | $1,122.02 | $1,122.02 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,000.00 / $4,677.35
| Facility | | $933.25 | $1,000.00 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,187.76 / $4,677.35
| Professional | | $1,819.70 | $2,187.76 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,467.37 / $4,677.35
| Professional | | $3,019.95 | $3,467.37 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,023.29 / $6,760.83
| Facility | | $933.25 | $1,023.29 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $812.83 / $2,818.38
| Professional | | $60.26 | $812.83 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $2,238.72 / $6,760.83
| Professional | | $977.24 | $2,238.72 | $6,760.83 |