- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $5,370.32 / $11,748.98
| Facility | | $1,737.80 | $5,370.32 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $3,630.78 / $11,748.98
| Professional | | $812.83 | $3,630.78 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $4,786.30 / $16,982.44
| Facility | | $1,258.93 | $4,786.30 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $47.86
| Professional | | $0.02 | $0.02 | $47.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $34.67 / $10,000.00
| Facility | | $34.67 | $34.67 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $851.14 / $1,096.48
| Professional | | $630.96 | $851.14 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $3,162.28 / $10,232.93
| Facility | | $851.14 | $3,162.28 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $50.12 / $1,047.13
| Professional | | $34.67 | $50.12 | $1,047.13 |