- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,388.44 / $3,388.44
| Facility | | $2,137.96 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $524.81 / $616.60
| Professional | | $489.78 | $524.81 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $1,584.89 / $1,819.70
| Facility | | $0.02 | $1,584.89 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Professional | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Facility | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $891.25
| Facility | | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $446.68 / $1,071.52
| Professional | | $316.23 | $446.68 | $1,071.52 |