- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $4,466.84 / $11,220.18
| Facility | | $870.96 | $4,466.84 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $676.08 / $1,380.38
| Professional | | $524.81 | $676.08 | $1,380.38 |
- 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
- $524.81 / $776.25 / $1,445.44
| Professional | | $524.81 | $776.25 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,548.82 / $4,786.30
| Facility | | $724.44 | $1,548.82 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $912.01 / $1,862.09
| Professional | | $562.34 | $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
- $501.19 / $741.31 / $1,380.38
| Professional | | $501.19 | $741.31 | $1,380.38 |