- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $7,244.36
| Facility | | $4,897.79 | $4,897.79 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $524.81 / $1,071.52
| Professional | | $380.19 | $524.81 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,235.94
| Facility | | $3,235.94 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $478.63 / $870.96
| Professional | | $346.74 | $478.63 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,479.11
| Facility | | $1,000.00 | $1,000.00 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $457.09 / $812.83
| Professional | | $331.13 | $457.09 | $812.83 |