- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $3,548.13 / $10,000.00
| Facility | | $512.86 | $3,548.13 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $467.74 / $1,047.13
| Professional | | $302.00 | $467.74 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,897.79 / $13,489.63
| Facility | | $2,454.71 | $4,897.79 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $467.74 / $891.25
| Professional | | $269.15 | $467.74 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $1,318.26 / $3,630.78
| Facility | | $501.19 | $1,318.26 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $575.44 / $1,230.27
| Professional | | $354.81 | $575.44 | $1,230.27 |
- 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
- $309.03 / $478.63 / $912.01
| Professional | | $309.03 | $478.63 | $912.01 |