- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,096.48 / $10,000.00
| Facility | | $1,047.13 | $1,096.48 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,122.02 / $1,778.28
| Professional | | $1,047.13 | $1,122.02 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,187.76 / $2,630.27
| Professional | | $1,778.28 | $2,187.76 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,905.46 / $3,162.28
| Professional | | $1,288.25 | $1,905.46 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,698.24 / $3,162.28
| Facility | | $1,047.13 | $1,698.24 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,862.09 / $8,912.51
| Professional | | $1,071.52 | $1,862.09 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,754.40 / $8,912.51
| Facility | | $4,677.35 | $5,754.40 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,659.59 / $2,630.27
| Professional | | $1,148.15 | $1,659.59 | $2,630.27 |