- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $5,128.61 / $6,918.31
| Facility | | $489.78 | $5,128.61 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $213.80 / $398.11
| Professional | | $181.97 | $213.80 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $218.78 / $3,548.13
| Professional | | $190.55 | $218.78 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $245.47 / $616.60
| Professional | | $181.97 | $245.47 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $204.17 / $398.11
| Professional | | $194.98 | $204.17 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $10,000.00 / $26,302.68
| Facility | | $2,344.23 | $10,000.00 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $213.80 / $478.63
| Professional | | $158.49 | $213.80 | $478.63 |