- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $2,630.27 / $10,000.00
| Facility | | $190.55 | $2,630.27 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $199.53 / $398.11
| Professional | | $114.82 | $199.53 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,630.78 / $9,120.11
| Facility | | $1,513.56 | $3,630.78 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $208.93 / $416.87
| Professional | | $114.82 | $208.93 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.89 / $281.84 / $1,548.82
| Facility | | $125.89 | $281.84 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $251.19 / $549.54
| Professional | | $134.90 | $251.19 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $1,949.84 / $4,677.35
| Facility | | $575.44 | $1,949.84 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $204.17 / $407.38
| Professional | | $120.23 | $204.17 | $407.38 |