- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $3,467.37 / $9,772.37
| Facility | | $616.60 | $3,467.37 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $489.78 / $1,071.52
| Professional | | $354.81 | $489.78 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $5,248.07 / $11,220.18
| Facility | | $2,089.30 | $5,248.07 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $478.63 / $954.99
| Professional | | $288.40 | $478.63 | $954.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $1,096.48 / $3,467.37
| Facility | | $478.63 | $1,096.48 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $630.96 / $1,288.25
| Professional | | $380.19 | $630.96 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,265.80 / $10,000.00
| Facility | | $1,513.56 | $4,265.80 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $512.86 / $954.99
| Professional | | $346.74 | $512.86 | $954.99 |