- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $7,244.36
| Facility | | $4,073.80 | $4,073.80 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $478.63 / $1,047.13
| Professional | | $389.05 | $478.63 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $489.78 / $707.95
| Professional | | $363.08 | $489.78 | $707.95 |
- 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
- $371.54 / $457.09 / $758.58
| Professional | | $371.54 | $457.09 | $758.58 |