- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $3,162.28 / $7,762.47
| Facility | | $707.95 | $3,162.28 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $616.60 / $1,348.96
| Professional | | $478.63 | $616.60 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $1,071.52 / $6,456.54
| Professional | | $575.44 | $1,071.52 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $575.44 / $1,584.89
| Professional | | $478.63 | $575.44 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $602.56 / $1,288.25
| Professional | | $524.81 | $602.56 | $1,288.25 |
- 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
- $380.19 / $549.54 / $1,479.11
| Professional | | $380.19 | $549.54 | $1,479.11 |