- 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
- $281.84 / $467.74 / $1,479.11
| Professional | | $281.84 | $467.74 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $263.03 / $954.99
| Professional | | $194.98 | $263.03 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $389.05 / $537.03
| Professional | | $208.93 | $389.05 | $537.03 |
- 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
- $218.78 / $398.11 / $602.56
| Professional | | $218.78 | $398.11 | $602.56 |