- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.40 / $4,803.39 / $7,304.88
| Facility | | $478.40 | $4,803.39 | $7,304.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.19 / $186.15 / $196.82
| Professional | | $168.19 | $186.15 | $196.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.91 / $239.74 / $305.66
| Professional | | $177.91 | $239.74 | $305.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,130.85 / $5,130.85 / $6,469.26
| Facility | | $5,130.85 | $5,130.85 | $6,469.26 |
- 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
- $168.11 / $228.57 / $449.45
| Professional | | $168.11 | $228.57 | $449.45 |