- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $4,073.80 / $4,570.88
| Facility | | $524.81 | $4,073.80 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $512.86 / $1,096.48
| Professional | | $389.05 | $512.86 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $1,778.28 / $4,073.80
| Professional | | $426.58 | $1,778.28 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $537.03 / $1,348.96
| Professional | | $380.19 | $537.03 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $588.84 / $1,096.48
| Professional | | $512.86 | $588.84 | $1,096.48 |
- 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
- $323.59 / $436.52 / $1,148.15
| Professional | | $323.59 | $436.52 | $1,148.15 |