- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $6,760.83 / $7,244.36
| Facility | | $4,073.80 | $6,760.83 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $416.87 / $954.99
| Professional | | $316.23 | $416.87 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $436.52 / $645.65
| Professional | | $331.13 | $436.52 | $645.65 |
- 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
- $309.03 / $398.11 / $645.65
| Professional | | $309.03 | $398.11 | $645.65 |