- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $4,073.80 / $7,762.47
| Facility | | $741.31 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $676.08 / $1,071.52
| Professional | | $562.34 | $676.08 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $676.08 / $2,818.38
| Professional | | $524.81 | $676.08 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $676.08 / $1,737.80
| Professional | | $512.86 | $676.08 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $676.08 / $1,412.54
| Professional | | $645.65 | $676.08 | $1,412.54 |
- 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
- $457.09 / $630.96 / $1,548.82
| Professional | | $457.09 | $630.96 | $1,548.82 |