- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,241.42 / $4,803.39 / $8,822.08
| Facility | | $2,241.42 | $4,803.39 | $8,822.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.02 / $188.02 / $202.44
| Professional | | $177.02 | $188.02 | $202.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.36 / $244.18 / $348.40
| Professional | | $181.36 | $244.18 | $348.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,825.23 / $3,825.23 / $7,544.08
| Facility | | $3,825.23 | $3,825.23 | $7,544.08 |
- 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
- $180.06 / $233.02 / $448.87
| Professional | | $180.06 | $233.02 | $448.87 |