- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $5,128.61 / $13,803.84
| Facility | | $891.25 | $5,128.61 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $676.08 / $1,380.38
| Professional | | $512.86 | $676.08 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $5,495.41 / $12,022.64
| Facility | | $2,630.27 | $5,495.41 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $776.25 / $1,479.11
| Professional | | $549.54 | $776.25 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $1,698.24 / $4,677.35
| Facility | | $831.76 | $1,698.24 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $912.01 / $1,862.09
| Professional | | $588.84 | $912.01 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,265.80 / $10,000.00
| Facility | | $1,513.56 | $4,265.80 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $776.25 / $1,412.54
| Professional | | $512.86 | $776.25 | $1,412.54 |