- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $3,981.07
| Facility | | $2,398.83 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $239.88 / $524.81
| Professional | | $120.23 | $239.88 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $229.09 / $436.52
| Professional | | $125.89 | $229.09 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $302.00 / $602.56
| Professional | | $114.82 | $302.00 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,128.61 / $10,000.00
| Facility | | $2,818.38 | $5,128.61 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $229.09 / $489.78
| Professional | | $138.04 | $229.09 | $489.78 |