- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,140.00 / $3,140.00 / $6,907.00
| Facility | | $3,140.00 | $3,140.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.25 / $540.02 / $679.11
| Professional | | $289.25 | $540.02 | $679.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,014.78 / $1,014.78 / $1,014.78
| Facility | | $1,014.78 | $1,014.78 | $1,014.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.17 / $582.99 / $1,057.67
| Professional | | $311.17 | $582.99 | $1,057.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,485.00
| Facility | | $1,000.00 | $1,000.00 | $1,485.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $528.92 / $638.74 / $1,454.31
| Professional | | $528.92 | $638.74 | $1,454.31 |