- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $3,235.94 / $10,000.00
| Facility | | $645.65 | $3,235.94 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $707.95 / $1,778.28
| Professional | | $213.80 | $707.95 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $7,413.10 / $13,803.84
| Facility | | $3,311.31 | $7,413.10 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $870.96 / $2,089.30
| Professional | | $239.88 | $870.96 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.78 / $2,951.21 / $9,332.54
| Facility | | $218.78 | $2,951.21 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $741.31 / $2,344.23
| Professional | | $245.47 | $741.31 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.15 / $1,174.90 / $3,630.78
| Facility | | $269.15 | $1,174.90 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $776.25 / $1,995.26
| Professional | | $218.78 | $776.25 | $1,995.26 |