- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $4,073.80 / $7,762.47
| Facility | | $407.38 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $407.38 / $1,122.02
| Professional | | $363.08 | $407.38 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $1,819.70 / $4,073.80
| Professional | | $257.04 | $1,819.70 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $457.09 / $1,023.29
| Professional | | $371.54 | $457.09 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $363.08 / $812.83
| Professional | | $346.74 | $363.08 | $812.83 |
- 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
- $309.03 / $436.52 / $1,000.00
| Professional | | $309.03 | $436.52 | $1,000.00 |