- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $2,818.38 / $8,709.64
| Facility | | $812.83 | $2,818.38 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $794.33 / $1,479.11
| Professional | | $588.84 | $794.33 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $4,168.69 / $10,000.00
| Facility | | $1,548.82 | $4,168.69 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $794.33 / $1,548.82
| Professional | | $562.34 | $794.33 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,548.82 / $5,495.41
| Facility | | $588.84 | $1,548.82 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $933.25 / $2,187.76
| Professional | | $575.44 | $933.25 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $4,168.69 / $9,549.93
| Facility | | $1,445.44 | $4,168.69 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $758.58 / $1,412.54
| Professional | | $537.03 | $758.58 | $1,412.54 |