- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,300.00 / $4,192.00 / $13,200.00
| Facility | | $1,300.00 | $4,192.00 | $13,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $334.51 / $334.51 / $334.51
| Professional | | $334.51 | $334.51 | $334.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,149.64 / $30,204.58 / $48,066.43
| Facility | | $19,149.64 | $30,204.58 | $48,066.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $334.51 / $6,926.00 / $20,697.14
| Facility | | $334.51 | $6,926.00 | $20,697.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.17 / $497.62 / $2,201.52
| Professional | | $346.17 | $497.62 | $2,201.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,960.00 / $9,469.00 / $20,190.00
| Facility | | $1,960.00 | $9,469.00 | $20,190.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.17 / $475.98 / $693.63
| Professional | | $346.17 | $475.98 | $693.63 |