- 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
- $263.03 / $354.81 / $776.25
| Professional | | $263.03 | $354.81 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $371.54 / $537.03
| Professional | | $275.42 | $371.54 | $537.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $3,388.44
| Facility | | $2,630.27 | $2,630.27 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $346.74 / $537.03
| Professional | | $275.42 | $346.74 | $537.03 |