- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $7,838.38 / $7,838.38
| Facility | | $1,000.00 | $7,838.38 | $7,838.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,744.74 / $1,814.99 / $1,914.56
| Professional | | $1,744.74 | $1,814.99 | $1,914.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $2,465.07
| Professional | | $60.00 | $60.00 | $2,465.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,085.00 / $4,262.00 / $17,636.00
| Facility | | $3,085.00 | $4,262.00 | $17,636.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,493.12 / $3,052.80 / $4,121.28
| Professional | | $2,493.12 | $3,052.80 | $4,121.28 |