- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $7,838.38 / $7,838.38
| Facility | | $1,000.00 | $7,838.38 | $7,838.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.37 / $981.37 / $981.37
| Professional | | $981.37 | $981.37 | $981.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $591.47 / $2,168.78 / $3,534.00
| Facility | | $591.47 | $2,168.78 | $3,534.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $401.60 / $3,500.00
| Professional | | $50.00 | $401.60 | $3,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $559.00 / $3,085.00 / $5,060.00
| Facility | | $559.00 | $3,085.00 | $5,060.00 |