- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $3,715.35 / $9,772.37
| Facility | | $891.25 | $3,715.35 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $537.03 / $1,148.15
| Professional | | $457.09 | $537.03 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,888.44 / $13,489.63
| Facility | | $2,290.87 | $5,888.44 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $676.08 / $1,258.93
| Professional | | $446.68 | $676.08 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,621.81 / $3,548.13
| Facility | | $870.96 | $1,621.81 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $758.58 / $1,548.82
| Professional | | $501.19 | $758.58 | $1,548.82 |
- 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
- $426.58 / $602.56 / $1,122.02
| Professional | | $426.58 | $602.56 | $1,122.02 |