- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $3,162.28 / $9,120.11
| Facility | | $741.31 | $3,162.28 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $426.58 / $1,023.29
| Professional | | $363.08 | $426.58 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $7,244.36 / $14,791.08
| Facility | | $2,187.76 | $7,244.36 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $501.19 / $1,023.29
| Professional | | $354.81 | $501.19 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,318.26 / $3,311.31
| Facility | | $676.08 | $1,318.26 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $602.56 / $1,288.25
| Professional | | $389.05 | $602.56 | $1,288.25 |
- 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
- $338.84 / $467.74 / $891.25
| Professional | | $338.84 | $467.74 | $891.25 |