- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $3,981.07 / $10,715.19
| Facility | | $758.58 | $3,981.07 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $616.60 / $1,258.93
| Professional | | $436.52 | $616.60 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,248.07 / $11,220.18
| Facility | | $2,290.87 | $5,248.07 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $691.83 / $1,318.26
| Professional | | $446.68 | $691.83 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $1,819.70 / $4,786.30
| Facility | | $660.69 | $1,819.70 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $812.83 / $1,819.70
| Professional | | $489.78 | $812.83 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $4,265.80 / $10,000.00
| Facility | | $1,584.89 | $4,265.80 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $676.08 / $1,258.93
| Professional | | $426.58 | $676.08 | $1,258.93 |