- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.40 / $2,818.38 / $7,943.28
| Facility | | $288.40 | $2,818.38 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $1,348.96 / $3,388.44
| Facility | | $660.69 | $1,348.96 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $588.84 / $1,412.54
| Facility | | $407.38 | $588.84 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $407.38 / $478.63
| Professional | | $407.38 | $407.38 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $371.54 / $575.44
| Facility | | $245.47 | $371.54 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $6,309.57 / $10,000.00
| Facility | | $616.60 | $6,309.57 | $10,000.00 |