- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $3,388.44 / $6,456.54
| Facility | | $478.63 | $3,388.44 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $389.05 / $691.83
| Professional | | $281.84 | $389.05 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $323.59 / $3,311.31
| Professional | | $269.15 | $323.59 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $407.38 / $1,148.15
| Professional | | $288.40 | $407.38 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $436.52 / $812.83
| Professional | | $371.54 | $436.52 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $10,000.00 / $26,302.68
| Facility | | $1,819.70 | $10,000.00 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $371.54 / $812.83
| Professional | | $251.19 | $371.54 | $812.83 |