- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $2,691.53 / $8,511.38
| Facility | | $363.08 | $2,691.53 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $281.84 / $616.60
| Professional | | $199.53 | $281.84 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $4,168.69 / $10,000.00
| Facility | | $1,548.82 | $4,168.69 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $323.59 / $645.65
| Professional | | $218.78 | $323.59 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $977.24 / $2,398.83
| Facility | | $338.84 | $977.24 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $371.54 / $794.33
| Professional | | $229.09 | $371.54 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,884.03 / $6,309.57
| Facility | | $1,000.00 | $2,884.03 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $316.23 / $602.56
| Professional | | $204.17 | $316.23 | $602.56 |