- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $7,585.78 / $13,182.57
| Facility | | $512.86 | $7,585.78 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $562.34
| Professional | | $512.86 | $512.86 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $4,265.80 / $4,265.80
| Professional | | $1,949.84 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $794.33 / $1,737.80
| Professional | | $223.87 | $794.33 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $724.44
| Facility | | $512.86 | $512.86 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.01 / $5.01 / $1,513.56
| Professional | | $5.01 | $5.01 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $12,589.25 / $19,054.61
| Facility | | $5,370.32 | $12,589.25 | $19,054.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,466.84 / $4,466.84
| Professional | | $2,754.23 | $4,466.84 | $4,466.84 |