- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $7,244.36 / $10,000.00
| Facility | | $6,456.54 | $7,244.36 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $954.99 / $2,454.71
| Professional | | $831.76 | $954.99 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $912.01
| Facility | | $912.01 | $912.01 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $954.99 / $1,659.59
| Professional | | $758.58 | $954.99 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $2,511.89
| Facility | | $1,995.26 | $1,995.26 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,023.29 / $1,621.81
| Professional | | $794.33 | $1,023.29 | $1,621.81 |