- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $4,570.88 / $11,220.18
| Facility | | $602.56 | $4,570.88 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $446.68 / $1,096.48
| Professional | | $338.84 | $446.68 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $5,754.40 / $12,882.50
| Facility | | $2,570.40 | $5,754.40 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $549.54 / $1,000.00
| Professional | | $380.19 | $549.54 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $1,000.00 / $3,235.94
| Facility | | $398.11 | $1,000.00 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $630.96 / $1,318.26
| Professional | | $407.38 | $630.96 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $3,235.94 / $10,471.29
| Facility | | $851.14 | $3,235.94 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $524.81 / $954.99
| Professional | | $371.54 | $524.81 | $954.99 |