- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $4,570.88 / $11,220.18
| Facility | | $724.44 | $4,570.88 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $549.54 / $1,096.48
| Professional | | $380.19 | $549.54 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $7,244.36 / $14,791.08
| Facility | | $2,818.38 | $7,244.36 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $588.84 / $1,096.48
| Professional | | $346.74 | $588.84 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $1,513.56 / $4,265.80
| Facility | | $645.65 | $1,513.56 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $707.95 / $1,479.11
| Professional | | $436.52 | $707.95 | $1,479.11 |
- 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
- $380.19 / $588.84 / $1,096.48
| Professional | | $380.19 | $588.84 | $1,096.48 |