- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $5,128.61 / $7,762.47
| Facility | | $912.01 | $5,128.61 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $912.01 / $2,344.23
| Professional | | $831.76 | $912.01 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $933.25 / $5,495.41
| Professional | | $537.03 | $933.25 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,071.52 / $2,290.87
| Professional | | $812.83 | $1,071.52 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $794.33 / $1,778.28
| Professional | | $758.58 | $794.33 | $1,778.28 |
- 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
- $707.95 / $977.24 / $2,238.72
| Professional | | $707.95 | $977.24 | $2,238.72 |