- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $3,235.94 / $6,760.83
| Facility | | $1,258.93 | $3,235.94 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $812.83 / $1,659.59
| Professional | | $478.63 | $812.83 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,137.96 / $7,079.46
| Facility | | $1,000.00 | $2,137.96 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,513.56 / $1,778.28
| Professional | | $1,000.00 | $1,513.56 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,754.40 / $7,585.78
| Facility | | $3,311.31 | $5,754.40 | $7,585.78 |