- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $4,265.80 / $10,715.19
| Facility | | $891.25 | $4,265.80 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $602.56 / $1,513.56
| Professional | | $512.86 | $602.56 | $1,513.56 |
- 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
- $501.19 / $741.31 / $1,412.54
| Professional | | $501.19 | $741.31 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,862.09 / $4,265.80
| Facility | | $977.24 | $1,862.09 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $831.76 / $1,862.09
| Professional | | $562.34 | $831.76 | $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
- $478.63 / $660.69 / $1,258.93
| Professional | | $478.63 | $660.69 | $1,258.93 |