- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $3,467.37 / $6,760.83
| Facility | | $1,000.00 | $3,467.37 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $758.58 / $1,348.96
| Professional | | $660.69 | $758.58 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $977.24 / $1,174.90
| Professional | | $758.58 | $977.24 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,202.26 / $5,888.44
| Facility | | $724.44 | $1,202.26 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $851.14 / $6,760.83
| Professional | | $630.96 | $851.14 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $3,311.31 / $6,025.60
| Facility | | $891.25 | $3,311.31 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $741.31 / $1,023.29
| Professional | | $588.84 | $741.31 | $1,023.29 |