- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $3,801.89 / $10,471.29
| Facility | | $741.31 | $3,801.89 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $630.96 / $1,348.96
| Professional | | $446.68 | $630.96 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $7,079.46 / $14,454.40
| Facility | | $2,818.38 | $7,079.46 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $602.56 / $1,202.26
| Professional | | $302.00 | $602.56 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $1,621.81 / $4,897.79
| Facility | | $549.54 | $1,621.81 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $776.25 / $1,698.24
| Professional | | $457.09 | $776.25 | $1,698.24 |
- 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
- $416.87 / $645.65 / $1,230.27
| Professional | | $416.87 | $645.65 | $1,230.27 |