- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $3,235.94 / $8,912.51
| Facility | | $630.96 | $3,235.94 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $512.86 / $3,981.07
| Professional | | $234.42 | $512.86 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,168.69 / $10,000.00
| Facility | | $1,513.56 | $4,168.69 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $588.84 / $4,073.80
| Professional | | $275.42 | $588.84 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $724.44 / $8,912.51
| Facility | | $371.54 | $724.44 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $630.96 / $5,248.07
| Professional | | $269.15 | $630.96 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $2,570.40 / $6,165.95
| Facility | | $660.69 | $2,570.40 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $524.81 / $4,168.69
| Professional | | $234.42 | $524.81 | $4,168.69 |