- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $3,890.45 / $10,000.00
| Facility | | $812.83 | $3,890.45 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $660.69 / $1,862.09
| Professional | | $467.74 | $660.69 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $7,079.46 / $14,454.40
| Facility | | $2,454.71 | $7,079.46 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $602.56 / $1,258.93
| Professional | | $389.05 | $602.56 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $1,412.54 / $3,801.89
| Facility | | $602.56 | $1,412.54 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $741.31 / $1,621.81
| Professional | | $457.09 | $741.31 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,265.80 / $9,772.37
| Facility | | $1,513.56 | $4,265.80 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $575.44 / $1,148.15
| Professional | | $407.38 | $575.44 | $1,148.15 |