- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $7,244.36
| Facility | | $3,235.94 | $3,235.94 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $446.68 / $741.31
| Professional | | $302.00 | $446.68 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $354.81
| Facility | | $354.81 | $354.81 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $407.38 / $758.58
| Professional | | $269.15 | $407.38 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,023.29 / $1,479.11
| Facility | | $1,000.00 | $1,023.29 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $363.08 / $575.44
| Professional | | $257.04 | $363.08 | $575.44 |