- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,890.45 / $10,000.00
| Facility | | $1,513.56 | $3,890.45 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,513.56 / $1,905.46
| Professional | | $1,288.25 | $1,513.56 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.09 / $1,479.11 / $2,187.76
| Facility | | $457.09 | $1,479.11 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,412.54 / $2,754.23
| Professional | | $1,380.38 | $1,412.54 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,479.11 / $5,370.32
| Facility | | $1,096.48 | $1,479.11 | $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 / $9,772.37
| Professional | | $812.83 | $812.83 | $9,772.37 |
- 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 |