- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $5,888.44 / $9,120.11
| Facility | | $912.01 | $5,888.44 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $467.74 / $1,023.29
| Professional | | $363.08 | $467.74 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $489.78 / $660.69
| Professional | | $407.38 | $489.78 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $6,456.54
| Facility | | $6,456.54 | $6,456.54 | $6,456.54 |
- 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
- $316.23 / $416.87 / $691.83
| Professional | | $316.23 | $416.87 | $691.83 |