- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,630.27 / $4,570.88
| Facility | | $1,174.90 | $2,630.27 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,548.82 / $2,630.27
| Professional | | $1,000.00 | $1,548.82 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $0.03
| Professional | | $0.02 | $0.02 | $0.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $2,570.40 / $3,311.31
| Facility | | $794.33 | $2,570.40 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $630.96 / $630.96
| Professional | | $630.96 | $630.96 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $2,691.53
| Facility | | $1,548.82 | $1,548.82 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $10,000.00 / $10,964.78
| Facility | | $4,073.80 | $10,000.00 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $10,000.00 / $10,964.78
| Professional | | $4,073.80 | $10,000.00 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $1,122.02 / $3,388.44
| Facility | | $446.68 | $1,122.02 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,122.02
| Professional | | $1,122.02 | $1,122.02 | $1,122.02 |