- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $4,786.30 / $11,481.54
| Facility | | $933.25 | $4,786.30 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $489.78 / $1,096.48
| Professional | | $407.38 | $489.78 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $7,585.78 / $14,791.08
| Facility | | $2,691.53 | $7,585.78 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $562.34 / $1,096.48
| Professional | | $371.54 | $562.34 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,445.44 / $3,388.44
| Facility | | $724.44 | $1,445.44 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $660.69 / $1,412.54
| Professional | | $426.58 | $660.69 | $1,412.54 |
- 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
- $363.08 / $524.81 / $977.24
| Professional | | $363.08 | $524.81 | $977.24 |