- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $3,162.28 / $7,762.47
| Facility | | $436.52 | $3,162.28 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $398.11 / $645.65
| Professional | | $346.74 | $398.11 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $407.38 / $3,235.94
| Professional | | $338.84 | $407.38 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $407.38 / $1,047.13
| Professional | | $309.03 | $407.38 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $416.87 / $851.14
| Professional | | $398.11 | $416.87 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $10,000.00 / $26,915.35
| Facility | | $3,311.31 | $10,000.00 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $380.19 / $891.25
| Professional | | $275.42 | $380.19 | $891.25 |