- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $3,162.28 / $9,332.54
| Facility | | $776.25 | $3,162.28 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $489.78 / $1,096.48
| Professional | | $416.87 | $489.78 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $4,168.69 / $10,000.00
| Facility | | $1,548.82 | $4,168.69 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $588.84 / $1,122.02
| Professional | | $407.38 | $588.84 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,318.26 / $3,467.37
| Facility | | $794.33 | $1,318.26 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- 54
- Low / Median / High Price
- $562.34 / $562.34 / $562.34
| Facility | 54 | $562.34 | $562.34 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $676.08 / $1,479.11
| Professional | | $457.09 | $676.08 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $1,258.93 / $3,981.07
| Facility | | $302.00 | $1,258.93 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $537.03 / $1,000.00
| Professional | | $389.05 | $537.03 | $1,000.00 |