- 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
- $1,212.58 / $2,001.64 / $2,169.67
| Professional | | $1,212.58 | $2,001.64 | $2,169.67 |
- 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
- $2,027.21 / $2,678.74 / $5,303.27
| Professional | | $2,027.21 | $2,678.74 | $5,303.27 |