- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,659.59 / $4,168.69
| Facility | | $676.08 | $1,659.59 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $891.25 / $1,258.93
| Professional | | $724.44 | $891.25 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,481.54 / $19,498.45 / $28,183.83
| Facility | | $11,481.54 | $19,498.45 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,071.52 / $1,348.96
| Professional | | $912.01 | $1,071.52 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,023.29 / $1,412.54
| Professional | | $645.65 | $1,023.29 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $10,000.00 / $24,547.09
| Facility | | $1,202.26 | $10,000.00 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,000.00 / $1,698.24
| Professional | | $724.44 | $1,000.00 | $1,698.24 |