- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $4,265.80 / $10,715.19
| Facility | | $851.14 | $4,265.80 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $467.74 / $1,047.13
| Professional | | $398.11 | $467.74 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $7,079.46 / $14,454.40
| Facility | | $2,818.38 | $7,079.46 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $616.60 / $1,122.02
| Professional | | $398.11 | $616.60 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $1,380.38 / $3,311.31
| Facility | | $645.65 | $1,380.38 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $676.08 / $1,445.44
| Professional | | $446.68 | $676.08 | $1,445.44 |
- 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
- $371.54 / $537.03 / $1,000.00
| Professional | | $371.54 | $537.03 | $1,000.00 |