- 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
- $446.68 / $524.81 / $1,174.90
| Professional | | $446.68 | $524.81 | $1,174.90 |
- 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
- $436.52 / $660.69 / $1,230.27
| Professional | | $436.52 | $660.69 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,513.56 / $3,715.35
| Facility | | $676.08 | $1,513.56 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $741.31 / $1,621.81
| Professional | | $501.19 | $741.31 | $1,621.81 |
- 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
- $416.87 / $588.84 / $1,096.48
| Professional | | $416.87 | $588.84 | $1,096.48 |