- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $3,715.35 / $10,471.29
| Facility | | $630.96 | $3,715.35 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $602.56 / $1,288.25
| Professional | | $407.38 | $602.56 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $6,025.60 / $13,489.63
| Facility | | $2,630.27 | $6,025.60 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $588.84 / $1,096.48
| Professional | | $316.23 | $588.84 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $1,862.09 / $4,466.84
| Facility | | $741.31 | $1,862.09 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $724.44 / $1,548.82
| Professional | | $446.68 | $724.44 | $1,548.82 |
- 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
- $389.05 / $602.56 / $1,148.15
| Professional | | $389.05 | $602.56 | $1,148.15 |