- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,398.83 / $3,235.94
| Facility | | $1,258.93 | $2,398.83 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $630.96 / $891.25
| Professional | | $562.34 | $630.96 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $7,413.10 / $10,000.00
| Facility | | $6,309.57 | $7,413.10 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $602.56 / $741.31
| Professional | | $426.58 | $602.56 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $776.25 / $1,096.48
| Professional | | $478.63 | $776.25 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $5,370.32 / $9,772.37
| Facility | | $1,698.24 | $5,370.32 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $660.69 / $1,023.29
| Professional | | $478.63 | $660.69 | $1,023.29 |