- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $5,248.07 / $10,000.00
| Facility | | $1,479.11 | $5,248.07 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,698.24 / $2,570.40
| Professional | | $1,479.11 | $1,698.24 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,290.87 / $2,951.21
| Professional | | $2,137.96 | $2,290.87 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $5,248.07 / $12,022.64
| Facility | | $1,380.38 | $5,248.07 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,819.70 / $3,630.78
| Facility | | $1,584.89 | $1,819.70 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,137.96 / $2,570.40
| Facility | | $1,905.46 | $2,137.96 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,288.25 / $2,137.96
| Professional | | $891.25 | $1,288.25 | $2,137.96 |