- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.78 / $218.78 / $6,760.83
| Facility | | $218.78 | $218.78 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $229.09 / $275.42
| Professional | | $173.78 | $229.09 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $10,000.00 / $28,840.32
| Facility | | $4,897.79 | $10,000.00 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $309.03 / $309.03
| Professional | | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.78 / $407.38 / $10,471.29
| Facility | | $218.78 | $407.38 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $416.87 / $954.99
| Professional | | $239.88 | $416.87 | $954.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $8,709.64 / $11,748.98
| Facility | | $1,584.89 | $8,709.64 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $371.54 / $776.25
| Professional | | $245.47 | $371.54 | $776.25 |