- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $3,162.28 / $7,762.47
| Facility | | $213.80 | $3,162.28 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $190.55 / $331.13
| Professional | | $165.96 | $190.55 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $199.53 / $3,235.94
| Professional | | $173.78 | $199.53 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $204.17 / $512.86
| Professional | | $151.36 | $204.17 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $199.53 / $416.87
| Professional | | $190.55 | $199.53 | $416.87 |
- 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
- $134.90 / $190.55 / $446.68
| Professional | | $134.90 | $190.55 | $446.68 |