- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $791.70 / $3,695.07 / $8,373.50
| Facility | | $791.70 | $3,695.07 | $8,373.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $791.70 / $791.70 / $791.70
| Professional | | $791.70 | $791.70 | $791.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,195.00 / $10,269.77 / $18,959.32
| Facility | | $5,195.00 | $10,269.77 | $18,959.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $854.19 / $912.04 / $1,536.46
| Professional | | $854.19 | $912.04 | $1,536.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,061.24 / $1,061.24 / $4,467.06
| Facility | | $1,061.24 | $1,061.24 | $4,467.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.00 / $1,143.44 / $2,227.00
| Professional | | $525.00 | $1,143.44 | $2,227.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,283.50 / $3,297.00 / $8,175.00
| Facility | | $1,283.50 | $3,297.00 | $8,175.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $968.45 / $1,362.18 / $2,185.94
| Professional | | $968.45 | $1,362.18 | $2,185.94 |