- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $463.03 / $1,030.82 / $4,750.00
| Facility | | $463.03 | $1,030.82 | $4,750.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.17 / $356.46 / $439.74
| Professional | | $180.17 | $356.46 | $439.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,294.91 / $5,294.91 / $5,294.91
| Facility | | $5,294.91 | $5,294.91 | $5,294.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.09 / $440.19 / $741.44
| Professional | | $197.09 | $440.19 | $741.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,214.83 / $1,214.83 / $1,214.83
| Facility | | $1,214.83 | $1,214.83 | $1,214.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,200.00 / $2,200.00 / $2,200.00
| Facility | | $2,200.00 | $2,200.00 | $2,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.86 / $511.61 / $924.29
| Professional | | $341.86 | $511.61 | $924.29 |