- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $3,162.28 / $9,549.93
| Facility | | $812.83 | $3,162.28 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $575.44 / $1,380.38
| Professional | | $478.63 | $575.44 | $1,380.38 |
- 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
- $457.09 / $676.08 / $1,318.26
| Professional | | $457.09 | $676.08 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,659.59 / $4,073.80
| Facility | | $776.25 | $1,659.59 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $812.83 / $1,819.70
| Professional | | $501.19 | $812.83 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $7,079.46 / $15,488.17
| Facility | | $2,454.71 | $7,079.46 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $645.65 / $1,230.27
| Professional | | $446.68 | $645.65 | $1,230.27 |