- 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
- $213.80 / $309.03 / $426.58
| Professional | | $213.80 | $309.03 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $60.26 / $2,187.76
| Professional | | $50.12 | $60.26 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $346.74 / $478.63
| Facility | | $213.80 | $346.74 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $9,120.11 / $14,125.38
| Facility | | $794.33 | $9,120.11 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $426.58 / $588.84
| Professional | | $295.12 | $426.58 | $588.84 |