- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $11,748.98
| Facility | | $1,230.27 | $1,230.27 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $812.83 / $1,174.90
| Professional | | $467.74 | $812.83 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $588.84 / $851.14
| Professional | | $426.58 | $588.84 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,025.60 / $7,244.36
| Facility | | $6,025.60 | $6,025.60 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $549.54 / $851.14
| Professional | | $457.09 | $549.54 | $851.14 |