- 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
- $302.00 / $363.08 / $707.95
| Professional | | $302.00 | $363.08 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $389.05 / $630.96
| Professional | | $309.03 | $389.05 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $3,981.07 / $3,981.07
| Facility | | $676.08 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $524.81 / $794.33
| Professional | | $245.47 | $524.81 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $4,265.80 / $10,000.00
| Facility | | $1,047.13 | $4,265.80 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $436.52 / $724.44
| Professional | | $302.00 | $436.52 | $724.44 |