- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $8,511.38 / $10,000.00
| Facility | | $316.23 | $8,511.38 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $316.23 / $562.34
| Professional | | $281.84 | $316.23 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $407.38 / $891.25
| Facility | | $295.12 | $407.38 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $562.34 / $741.31
| Professional | | $316.23 | $562.34 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,041.74
| Facility | | $1,819.70 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $562.34 / $776.25
| Professional | | $338.84 | $562.34 | $776.25 |