- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,955.04 / $15,000.00
| Facility | | $3,706.14 | $3,955.04 | $15,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,042.10 / $2,137.46 / $2,268.42
| Professional | | $1,042.10 | $2,137.46 | $2,268.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $9,442.60 / $11,134.41
| Facility | | $0.02 | $9,442.60 | $11,134.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,649.00 / $4,915.00 / $7,205.00
| Facility | | $1,649.00 | $4,915.00 | $7,205.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,070.46 / $2,699.11 / $4,385.97
| Professional | | $2,070.46 | $2,699.11 | $4,385.97 |