- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $3,090.30 / $10,715.19
| Facility | | $575.44 | $3,090.30 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $549.54 / $1,000.00
| Professional | | $169.82 | $549.54 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $10,000.00 / $16,982.44
| Facility | | $4,570.88 | $10,000.00 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $691.83 / $1,621.81
| Professional | | $177.83 | $691.83 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.21 / $1,778.28 / $6,309.57
| Facility | | $186.21 | $1,778.28 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $575.44 / $1,698.24
| Professional | | $204.17 | $575.44 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $1,202.26 / $3,801.89
| Facility | | $295.12 | $1,202.26 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $602.56 / $1,479.11
| Professional | | $177.83 | $602.56 | $1,479.11 |