- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $3,162.28 / $9,332.54
| Facility | | $645.65 | $3,162.28 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $407.38 / $758.58
| Professional | | $331.13 | $407.38 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $4,570.88 / $10,000.00
| Facility | | $1,778.28 | $4,570.88 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $446.68 / $794.33
| Professional | | $309.03 | $446.68 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $588.84 / $2,398.83
| Facility | | $302.00 | $588.84 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $489.78 / $954.99
| Professional | | $331.13 | $489.78 | $954.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $1,096.48 / $3,388.44
| Facility | | $251.19 | $1,096.48 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $407.38 / $724.44
| Professional | | $302.00 | $407.38 | $724.44 |