- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,890.45 / $10,000.00
| Facility | | $1,479.11 | $3,890.45 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,513.56 / $1,862.09
| Professional | | $1,288.25 | $1,513.56 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,981.07 / $5,888.44
| Facility | | $1,230.27 | $3,981.07 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,905.46 / $3,715.35
| Professional | | $1,862.09 | $1,905.46 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,513.56 / $5,370.32
| Facility | | $1,148.15 | $1,513.56 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,949.84 / $3,548.13
| Facility | | $1,288.25 | $1,949.84 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $9,549.93
| Professional | | $812.83 | $812.83 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,949.84 / $2,344.23
| Facility | | $1,737.80 | $1,949.84 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $1,174.90
| Professional | | $812.83 | $812.83 | $1,174.90 |