- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $3,388.44 / $9,120.11
| Facility | | $524.81 | $3,388.44 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $407.38 / $794.33
| Professional | | $263.03 | $407.38 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,888.44 / $13,489.63
| Facility | | $2,290.87 | $5,888.44 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $407.38 / $758.58
| Professional | | $239.88 | $407.38 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $1,122.02 / $3,090.30
| Facility | | $446.68 | $1,122.02 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $512.86 / $1,071.52
| Professional | | $309.03 | $512.86 | $1,071.52 |
- 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
- $263.03 / $426.58 / $794.33
| Professional | | $263.03 | $426.58 | $794.33 |