- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $4,365.16 / $10,964.78
| Facility | | $977.24 | $4,365.16 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $645.65 / $1,380.38
| Professional | | $549.54 | $645.65 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $7,079.46 / $14,791.08
| Facility | | $2,818.38 | $7,079.46 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $794.33 / $1,513.56
| Professional | | $537.03 | $794.33 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,698.24 / $4,365.16
| Facility | | $776.25 | $1,698.24 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $912.01 / $1,905.46
| Professional | | $602.56 | $912.01 | $1,905.46 |
- 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
- $512.86 / $724.44 / $1,348.96
| Professional | | $512.86 | $724.44 | $1,348.96 |