- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $5,128.61 / $7,762.47
| Facility | | $724.44 | $5,128.61 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $676.08 / $1,174.90
| Professional | | $549.54 | $676.08 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $645.65 / $1,023.29
| Professional | | $575.44 | $645.65 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $707.95 / $1,737.80
| Professional | | $524.81 | $707.95 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $660.69 / $1,412.54
| Professional | | $630.96 | $660.69 | $1,412.54 |
- 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
- $489.78 / $676.08 / $1,513.56
| Professional | | $489.78 | $676.08 | $1,513.56 |