- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $5,888.44 / $10,964.78
| Facility | | $954.99 | $5,888.44 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $6,760.83 / $7,413.10
| Facility | | $5,888.44 | $6,760.83 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $645.65 / $645.65
| Facility | | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,023.29 / $1,202.26
| Professional | | $794.33 | $1,023.29 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,380.38 / $2,041.74
| Professional | | $1,096.48 | $1,380.38 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,096.48 / $1,737.80
| Facility | | $794.33 | $1,096.48 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,096.48 / $10,000.00
| Facility | | $776.25 | $1,096.48 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $12,882.50 / $29,512.09
| Facility | | $7,413.10 | $12,882.50 | $29,512.09 |