- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $4,466.84 / $10,000.00
| Facility | | $1,047.13 | $4,466.84 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $870.96 / $8,317.64
| Professional | | $549.54 | $870.96 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $323.59 / $323.59
| Facility | | $323.59 | $323.59 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $50.12 / $50.12
| Professional | | $50.12 | $50.12 | $50.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $12,022.64 / $18,620.87
| Facility | | $3,235.94 | $12,022.64 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $208.93 / $208.93
| Professional | | $208.93 | $208.93 | $208.93 |