- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,500.00 / $4,316.00 / $9,244.00
| Facility | | $1,500.00 | $4,316.00 | $9,244.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $752.18 / $1,807.74 / $2,165.88
| Professional | | $752.18 | $1,807.74 | $2,165.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.77 / $638.07 / $801.00
| Professional | | $257.77 | $638.07 | $801.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,154.11 / $5,414.80 / $12,000.00
| Facility | | $1,154.11 | $5,414.80 | $12,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,058.35 / $2,058.35 / $2,058.35
| Professional | | $2,058.35 | $2,058.35 | $2,058.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $85.00
| Professional | | $60.00 | $60.00 | $85.00 |