- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $3,162.28 / $9,549.93
| Facility | | $831.76 | $3,162.28 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $645.65 / $1,445.44
| Professional | | $436.52 | $645.65 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $4,466.84 / $12,022.64
| Facility | | $1,905.46 | $4,466.84 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $660.69 / $1,445.44
| Professional | | $398.11 | $660.69 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,445.44 / $3,801.89
| Facility | | $724.44 | $1,445.44 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $831.76 / $2,187.76
| Professional | | $478.63 | $831.76 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,951.21 / $6,456.54
| Facility | | $1,000.00 | $2,951.21 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $707.95 / $2,089.30
| Professional | | $426.58 | $707.95 | $2,089.30 |