- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $3,467.37 / $6,760.83
| Facility | | $1,000.00 | $3,467.37 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $562.34 / $812.83
| Professional | | $426.58 | $562.34 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $660.69 / $812.83
| Professional | | $489.78 | $660.69 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $3,548.13 / $8,709.64
| Facility | | $630.96 | $3,548.13 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $588.84 / $3,801.89
| Professional | | $416.87 | $588.84 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $4,265.80 / $8,317.64
| Facility | | $1,230.27 | $4,265.80 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $537.03 / $812.83
| Professional | | $407.38 | $537.03 | $812.83 |