- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $602.56 / $6,025.60
| Facility | | $398.11 | $602.56 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $275.42 / $630.96
| Professional | | $169.82 | $275.42 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $234.42 / $302.00
| Professional | | $147.91 | $234.42 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $4,570.88
| Facility | | $3,801.89 | $3,801.89 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $213.80 / $407.38
| Professional | | $147.91 | $213.80 | $407.38 |