- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $3,890.45 / $10,964.78
| Facility | | $676.08 | $3,890.45 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,023.29 / $1,445.44
| Professional | | $794.33 | $1,023.29 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,570.88 / $10,000.00
| Facility | | $1,819.70 | $4,570.88 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $707.95 / $1,862.09
| Professional | | $323.59 | $707.95 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $1,318.26 / $3,715.35
| Facility | | $338.84 | $1,318.26 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $1,202.26 / $2,089.30
| Professional | | $426.58 | $1,202.26 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $1,096.48 / $3,467.37
| Facility | | $263.03 | $1,096.48 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $446.68 / $812.83
| Professional | | $288.40 | $446.68 | $812.83 |