- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,467.37 / $3,467.37
| Facility | | $2,187.76 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $537.03 / $616.60
| Professional | | $501.19 | $537.03 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $1,621.81 / $1,819.70
| Facility | | $0.02 | $1,621.81 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Professional | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,344.23
| Facility | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $602.56
| Professional | | $602.56 | $602.56 | $602.56 |
- 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
- $316.23 / $457.09 / $1,096.48
| Professional | | $316.23 | $457.09 | $1,096.48 |