- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,140.00 / $6,907.00 / $16,920.45
| Facility | | $3,140.00 | $6,907.00 | $16,920.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $453.88 / $551.59 / $551.59
| Professional | | $453.88 | $551.59 | $551.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $618.97 / $786.81 / $1,125.45
| Professional | | $618.97 | $786.81 | $1,125.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $579.51 / $579.51 / $579.51
| Professional | | $579.51 | $579.51 | $579.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $505.70 / $687.75 / $1,461.72
| Professional | | $505.70 | $687.75 | $1,461.72 |