- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $4,073.80 / $4,570.88
| Facility | | $204.17 | $4,073.80 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $245.47 / $616.60
| Professional | | $199.53 | $245.47 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $1,949.84 / $5,128.61
| Professional | | $204.17 | $1,949.84 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $257.04 / $660.69
| Professional | | $199.53 | $257.04 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $257.04 / $524.81
| Professional | | $245.47 | $257.04 | $524.81 |
- 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
- $177.83 / $263.03 / $512.86
| Professional | | $177.83 | $263.03 | $512.86 |