- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,138.63 / $2,138.63 / $2,851.50
| Facility | | $2,138.63 | $2,138.63 | $2,851.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.00 / $1,201.00 / $1,201.00
| Professional | | $1,201.00 | $1,201.00 | $1,201.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $643.00 / $1,136.00 / $2,898.00
| Facility | | $643.00 | $1,136.00 | $2,898.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.86 / $423.88 / $436.61
| Professional | | $285.86 | $423.88 | $436.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $43,749.56 / $52,499.48 / $89,999.10
| Facility | | $43,749.56 | $52,499.48 | $89,999.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $950.50 / $950.50 / $950.50
| Facility | | $950.50 | $950.50 | $950.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,138.63 / $2,138.63 / $2,138.63
| Facility | | $2,138.63 | $2,138.63 | $2,138.63 |