- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,818.38 / $11,481.54
| Facility | | $2,398.83 | $2,818.38 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $831.76 / $1,548.82
| Professional | | $691.83 | $831.76 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,677.35 / $6,309.57
| Facility | | $3,467.37 | $4,677.35 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,445.44 / $2,041.74
| Professional | | $691.83 | $1,445.44 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,089.30
| Facility | | $2,089.30 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,348.96 / $2,290.87
| Professional | | $912.01 | $1,348.96 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,000.00 / $10,000.00 / $10,000.00
| Facility | | $10,000.00 | $10,000.00 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,230.27 / $1,819.70
| Professional | | $812.83 | $1,230.27 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,000.00 / $10,000.00 / $10,000.00
| Facility | | $10,000.00 | $10,000.00 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,230.27 / $2,187.76
| Professional | | $812.83 | $1,230.27 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $912.01
| Facility | | $575.44 | $575.44 | $912.01 |