- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,149.51 / $3,391.00 / $6,915.00
| Facility | | $1,149.51 | $3,391.00 | $6,915.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $875.94 / $2,548.63 / $6,084.76
| Facility | | $875.94 | $2,548.63 | $6,084.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,286.79 / $1,534.02 / $2,086.71
| Facility | | $1,286.79 | $1,534.02 | $2,086.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $500.00 / $830.32 / $2,500.00
| Facility | | $500.00 | $830.32 | $2,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $801.08 / $1,177.60 / $1,805.22
| Professional | | $801.08 | $1,177.60 | $1,805.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $625.00 / $3,218.00 / $5,272.00
| Facility | | $625.00 | $3,218.00 | $5,272.00 |