- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $5,128.61 / $6,918.31
| Facility | | $812.83 | $5,128.61 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $630.96 / $1,148.15
| Professional | | $467.74 | $630.96 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $2,290.87 / $6,456.54
| Professional | | $426.58 | $2,290.87 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $588.84 / $1,778.28
| Professional | | $426.58 | $588.84 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,047.13 / $1,445.44
| Professional | | $676.08 | $1,047.13 | $1,445.44 |
- 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
- $354.81 / $588.84 / $1,380.38
| Professional | | $354.81 | $588.84 | $1,380.38 |