- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $3,090.30 / $8,912.51
| Facility | | $537.03 | $3,090.30 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $501.19 / $1,148.15
| Professional | | $331.13 | $501.19 | $1,148.15 |
- 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
- $288.40 / $501.19 / $933.25
| Professional | | $288.40 | $501.19 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $1,380.38 / $3,890.45
| Facility | | $524.81 | $1,380.38 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $616.60 / $1,318.26
| Professional | | $380.19 | $616.60 | $1,318.26 |
- 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
- $331.13 / $512.86 / $977.24
| Professional | | $331.13 | $512.86 | $977.24 |