- 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
- $169.82 / $194.98 / $446.68
| Professional | | $169.82 | $194.98 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,548.82
| Facility | | $1,548.82 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $194.98 / $346.74
| Professional | | $147.91 | $194.98 | $346.74 |
- 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
- $138.04 / $173.78 / $269.15
| Professional | | $138.04 | $173.78 | $269.15 |