- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $3,090.30 / $8,709.64
| Facility | | $562.34 | $3,090.30 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $512.86 / $1,047.13
| Professional | | $323.59 | $512.86 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $5,754.40 / $13,489.63
| Facility | | $1,905.46 | $5,754.40 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $512.86 / $933.25
| Professional | | $302.00 | $512.86 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $1,380.38 / $3,890.45
| Facility | | $501.19 | $1,380.38 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $630.96 / $1,348.96
| Professional | | $380.19 | $630.96 | $1,348.96 |
- 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 |