- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,606.93 / $10,964.78
| Facility | | $4,466.84 | $6,606.93 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $407.38 / $1,288.25
| Professional | | $346.74 | $407.38 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $575.44 / $1,230.27
| Professional | | $363.08 | $575.44 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $436.52 / $602.56
| Professional | | $338.84 | $436.52 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,791.08 / $22,908.68 / $36,307.81
| Facility | | $14,791.08 | $22,908.68 | $36,307.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $512.86 / $1,548.82
| Professional | | $346.74 | $512.86 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $10,000.00 / $25,118.86
| Facility | | $4,786.30 | $10,000.00 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $457.09 / $1,000.00
| Professional | | $316.23 | $457.09 | $1,000.00 |