- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,548.82 / $3,981.07
| Facility | | $1,513.56 | $1,548.82 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $245.47 / $676.08
| Professional | | $134.90 | $245.47 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $223.87 / $398.11
| Professional | | $134.90 | $223.87 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $269.15 / $524.81
| Professional | | $177.83 | $269.15 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,128.61 / $10,000.00
| Facility | | $2,818.38 | $5,128.61 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $263.03 / $575.44
| Professional | | $141.25 | $263.03 | $575.44 |