- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $4,168.69 / $10,715.19
| Facility | | $758.58 | $4,168.69 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $354.81 / $812.83
| Professional | | $281.84 | $354.81 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $6,309.57 / $12,302.69
| Facility | | $2,511.89 | $6,309.57 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $416.87 / $794.33
| Professional | | $263.03 | $416.87 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $1,071.52 / $2,951.21
| Facility | | $416.87 | $1,071.52 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $489.78 / $1,071.52
| Professional | | $309.03 | $489.78 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $4,265.80 / $10,000.00
| Facility | | $1,584.89 | $4,265.80 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $398.11 / $724.44
| Professional | | $281.84 | $398.11 | $724.44 |