- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $4,073.80 / $7,762.47
| Facility | | $309.03 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $309.03 / $489.78
| Professional | | $269.15 | $309.03 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $316.23 / $6,309.57
| Professional | | $263.03 | $316.23 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $389.05 / $741.31
| Professional | | $263.03 | $389.05 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $275.42 / $602.56
| Professional | | $263.03 | $275.42 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $10,000.00 / $31,622.78
| Facility | | $3,311.31 | $10,000.00 | $31,622.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $323.59 / $660.69
| Professional | | $245.47 | $323.59 | $660.69 |