- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $2,691.53 / $10,000.00
| Facility | | $741.31 | $2,691.53 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $380.19 / $776.25
| Professional | | $251.19 | $380.19 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $281.84 / $467.74
| Professional | | $218.78 | $281.84 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $371.54 / $602.56
| Professional | | $151.36 | $371.54 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $7,585.78
| Facility | | $2,570.40 | $4,677.35 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $354.81 / $537.03
| Professional | | $251.19 | $354.81 | $537.03 |