- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $3,311.31 / $7,244.36
| Facility | | $933.25 | $3,311.31 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $549.54 / $1,148.15
| Professional | | $446.68 | $549.54 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $562.34
| Facility | | $562.34 | $562.34 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $512.86 / $812.83
| Professional | | $398.11 | $512.86 | $812.83 |
- 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
- $389.05 / $501.19 / $660.69
| Professional | | $389.05 | $501.19 | $660.69 |