- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $7,762.47 / $7,762.47
| Facility | | $1,000.00 | $7,762.47 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $616.60 / $1,479.11
| Professional | | $489.78 | $616.60 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $85.11
| Professional | | $60.26 | $60.26 | $85.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $173.78 / $1,380.38
| Facility | | $173.78 | $173.78 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $5,128.61 / $19,498.45
| Facility | | $3,090.30 | $5,128.61 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $758.58 / $1,318.26
| Professional | | $524.81 | $758.58 | $1,318.26 |