- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $4,073.80 / $6,456.54
| Facility | | $1,000.00 | $4,073.80 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $363.08 / $363.08
| Professional | | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $2,398.83 / $6,456.54
| Professional | | $549.54 | $2,398.83 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,905.46
| Professional | | $1,698.24 | $1,698.24 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $14,791.08 / $26,915.35
| Facility | | $3,311.31 | $14,791.08 | $26,915.35 |