- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $4,265.80 / $10,964.78
| Facility | | $512.86 | $4,265.80 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $467.74 / $977.24
| Professional | | $302.00 | $467.74 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $5,888.44 / $13,489.63
| Facility | | $2,187.76 | $5,888.44 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $467.74 / $870.96
| Professional | | $257.04 | $467.74 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $1,584.89 / $3,715.35
| Facility | | $562.34 | $1,584.89 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $562.34 / $1,230.27
| Professional | | $346.74 | $562.34 | $1,230.27 |
- 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
- $302.00 / $467.74 / $891.25
| Professional | | $302.00 | $467.74 | $891.25 |